Infection Control Lapses During Incontinence Care
Penalty
Summary
Staff failed to maintain a sanitary environment and adhere to infection prevention and control protocols during incontinence care for three residents. Observations revealed that hand hygiene was not performed correctly, with staff washing hands for less than the required 15 seconds and failing to perform hand hygiene between glove changes. In several instances, staff handled soiled incontinence pads improperly, such as holding a clean pad against their scrub pants and leaving a visibly soiled pad on a resident after toileting. Additionally, residents were not offered the opportunity to wash their hands after toileting, and staff did not always assess or change soiled briefs as needed. Interviews with staff and review of facility policies confirmed that proper hand hygiene should include at least 20 seconds of scrubbing, and gloves should be changed with hand hygiene performed between tasks. The facility's policy also specified that gloves do not replace handwashing and that hand hygiene is the final step after removing personal protective equipment. Despite these guidelines, staff actions did not align with policy requirements, resulting in multiple breaches of infection control practices during resident care.