Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
The facility failed to maintain proper infection control measures during incontinence care for a resident with pressure ulcers. The resident, who was severely cognitively impaired, at risk for pressure ulcers, and dependent on staff for toileting, was observed receiving care from two CNAs. Both CNAs donned gowns and gloves due to the resident being on Enhanced Barrier Precautions for wounds. During the cleaning process, soiled washcloths were placed directly onto the resident's fitted bed sheet instead of being immediately bagged. After cleaning, the soiled pad was removed and replaced, but the fitted sheet, which had come into contact with the soiled washcloths, was not changed. The resident was then covered with a clean sheet over the unchanged fitted sheet. Later, a washcloth with dried stool was found in the resident's windowsill, and smears of dry stool were observed on the fitted bed sheet. Interviews with staff confirmed that soiled linens and washcloths should have been placed in a plastic bag after use and that the soiled sheet should have been changed and bagged for transport to the soiled utility room. The facility's perineal care competency checklist also indicated that a plastic bag should be available for soiled linens, but this protocol was not followed during the observed care.