Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
Certified Nursing Assistant 1 (CNA1) failed to follow proper infection prevention and control practices while providing care to two residents who were on enhanced barrier precautions. During an observation, CNA1 was seen emptying a urinal for one resident and then immediately assisting another resident without changing their gown or mask and without performing hand hygiene. This was confirmed by both the Infection Preventionist nurse and CNA1, who acknowledged that gloves are changed between resident care, but the gown, mask, and hand hygiene were neglected in this instance. Both residents involved had significant medical conditions requiring enhanced barrier precautions. One resident had chronic respiratory failure, a tracheostomy, and a gastrostomy tube, and was severely cognitively impaired and fully dependent on staff for care. The other resident had muscle wasting, a gastrostomy tube, dementia, and was colonized with a multidrug-resistant organism (ESBL). Both residents were always incontinent and required dependent assistance for personal hygiene, increasing their vulnerability to infection. Facility policies and care plans for both residents specified that staff must perform hand hygiene and change PPE, including gowns and gloves, before and after providing care, especially when moving between residents. The facility's own infection control policy and staff interviews confirmed these requirements. However, CNA1 did not adhere to these protocols during the observed care, which was recognized as an infection control issue by the Infection Preventionist nurse and the Director of Nursing.