Failure to Follow Infection Control Practices During Incontinent Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices during incontinent care for two residents with significant cognitive and physical impairments. Observations revealed that staff, including nurse aides and certified nurse aides, did not change gloves or perform hand hygiene between dirty and clean tasks while providing care to residents who were incontinent of bladder and bowel. Specifically, after unfastening and removing urine-saturated briefs and washing the residents' buttocks and legs, staff proceeded to place clean briefs and secure them without changing gloves or performing hand hygiene in between these steps. Both residents involved had moderate cognitive impairment and required extensive assistance with activities of daily living, including toileting hygiene. The facility also lacked a policy addressing infection control practices during incontinent care. Interviews with the Infection Preventionist and the Director of Nursing confirmed that staff should have changed gloves and performed hand hygiene between dirty and clean tasks, while one staff member was unaware of any mistakes made during the care provided.