Failure to Follow Hand Hygiene and Infection Control During Incontinence Care
Penalty
Summary
A Certified Nursing Assistant (CNA) failed to follow proper hand hygiene and infection control procedures while providing incontinence care to a resident with moderate cognitive impairment and frequent incontinence. The CNA did not perform hand hygiene before or after assisting the resident with toileting, and continued to wear the same contaminated gloves while retrieving and handling clean clothing from the resident's closet. The CNA also placed the resident's wet pants on the floor instead of in a trash bag, as required by facility policy, and touched the resident's socks and wheelchair footrest with the same dirty gloves. Interviews with the CNA, Director of Nursing (DON), and Administrator confirmed that staff were instructed to use trash bags for soiled clothing and to avoid touching clean items or surfaces with dirty gloves to prevent cross contamination. Facility policy on hand hygiene requires staff to perform hand hygiene before and after direct resident contact, after contact with bodily fluids, after touching objects in the resident's vicinity, and after removing gloves. These procedures were not followed during the observed care episode.