Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control procedures during incontinence care for a resident with multiple diagnoses, including intracranial injury, dysphagia, atopic dermatitis, and neuromuscular bladder dysfunction. The resident, who was on enhanced barrier precautions and required proper hand hygiene, was observed receiving incontinence care where a CNA removed a soiled brief, then touched clean items such as a mechanical lift sling and its controls, and proceeded to shower the resident without changing gloves. The facility's policy requires hand hygiene after contact with contaminated surfaces and before moving from a soiled to a clean body site, which was not followed during this care event.