Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
During an observation of peri-care for Resident #9, Certified Nursing Assistant (CNA) #1 placed items on the nightstand without using a barrier, contrary to facility policy. Both CNAs washed their hands and donned clean gloves before CNA #1 began cleaning the resident's vaginal area, pulling wipes from the pack multiple times while wearing soiled gloves. The resident had feces present in the back of her brief. After removing gloves and sanitizing hands, CNA #1 continued care in the buttocks area but again pulled wipes from the pack with contaminated gloves. CNA #1 acknowledged during an interview that wipes should not have been pulled from the pack with soiled gloves and that a barrier should have been used on the bedside table, with all needed wipes removed prior to starting care. Interviews with CNA #2, the Infection Preventionist (RN #1), and the Director of Nursing (DON) confirmed that the established procedures for peri-care were not followed, specifically regarding the prevention of cross-contamination. The facility's policy requires the use of a barrier and proper glove hygiene to prevent infection. Resident #9, who is dependent on toileting and hygiene and has diagnoses including acute kidney failure and vascular dementia, was at risk due to these lapses in infection control practices.