Failure to Follow Infection Control Standards During Resident Personal Care
Penalty
Summary
A deficiency occurred when a nursing assistant (NA-I) failed to follow current infection control standards during personal care for a resident diagnosed with diabetes, stroke, and heart disease. The resident required significant assistance with bed mobility, dressing, toileting, and transferring. During observed care, NA-I, after performing perineal care with gloved hands, continued to assist the resident with applying a new pad, putting on shorts, positioning on a stand aide, and adjusting glasses, all without changing gloves or performing hand hygiene between tasks. NA-J, another nursing assistant, performed hand hygiene before leaving the room, but NA-I only removed gloves and disposed of trash before leaving, without hand hygiene during the care process. Interview with NA-I revealed that he was not aware of the need to perform hand hygiene during care, only before and after. The director of nursing confirmed that facility policy requires hand hygiene before applying gloves, when changing gloves, after glove use, and after tasks such as perineal care to prevent cross-contamination. The facility's hand hygiene policy also specifies hand hygiene before moving from a contaminated to a clean body site, after contact with intact skin, and after removing gloves. The failure to follow these protocols was directly observed and confirmed through staff interviews and policy review.