Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow required infection prevention and control protocols during the care of three residents. In one instance, two CNAs transferred a resident who was on contact isolation for MRSA of the foot without wearing gowns, despite a posted sign and physician order requiring both gloves and gowns for entry into the room. The Director of Nursing confirmed that the appropriate personal protective equipment (PPE) was not used during this transfer. Another resident with a history of diarrhea, legal blindness, and physical debility was left in soiled incontinence for an extended period, resulting in discomfort and pain. During incontinence care, a CNA used the same soiled gloves to clean the resident's perineal area, assist with repositioning, and handle clean items, without changing gloves or performing hand hygiene between tasks. The CNA acknowledged that gloves should have been changed and hands cleaned between steps, and that clean items should not have been touched with soiled gloves. A third resident with a urinary catheter and a diagnosis of chronic lymphocytic leukemia and urinary tract infection received incontinence and catheter care from a CNA who failed to change gloves or perform hand hygiene between tasks. The CNA also did not follow proper technique for cleaning the catheter and surrounding area, using the same area of a washcloth for multiple strokes and not cleaning the full length of the catheter tubing as required by facility policy. The CNA later confirmed these lapses in infection control practice.