Failure to Follow Infection Control Protocols During Resident Hygiene Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to adhere to infection control standards during hygiene care for a resident on enhanced barrier precautions. The CNA did not perform hand hygiene before the procedure, nor did she change gloves or washcloths at appropriate intervals. The CNA was observed wearing a gown, mask, and gloves upon entry, but did not remove gloves or perform hand hygiene at any point during the care. The same washcloth was used to cleanse the resident's face and the rest of the body, and the resident was left uncovered while the basin was filled with water and soap was added directly to the water. The resident involved had a percutaneous endoscopic gastrostomy (PEG) tube and was under enhanced barrier precautions as ordered by a physician. The resident was cognitively impaired, fully dependent for activities of daily living, and had multiple diagnoses including dysphagia, diabetes mellitus, osteoarthritis, hyperlipidemia, dementia, and GERD. The care plan specified the need for enhanced barrier precautions during hygiene care, including education for caregivers and adherence to infection control guidelines. Facility policy required staff to maintain resident dignity by keeping them covered during care, to use a clean part of the washcloth for each body area, and to perform hand hygiene in conjunction with glove use. Staff interviews confirmed knowledge of these protocols, including the need to change gloves and use separate washcloths for different body areas. However, the observed care did not follow these established procedures, resulting in a failure to meet infection control standards.