Failure to Follow Infection Control Guidelines During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow infection control guidelines during incontinence care for a resident with multiple medical conditions, including left side hemiplegia, cognitive communication deficit, atrial fibrillation, and hypertension. The resident was dependent on staff for all activities of daily living and required enhanced barrier precautions due to a gastrostomy tube. Physician orders and the resident's care plan specified that staff were to use personal protective equipment (PPE), including gloves and a gown, during personal care. However, during an observed episode of incontinence care, the CNA donned gloves but did not wear a gown as required. During the care, the CNA removed soiled linens and a brief contaminated with fecal matter and placed them on the floor next to the resident's bed. After cleansing the resident's perineal area, the CNA, still wearing the same soiled gloves, touched clean linens and various surfaces in the room, including the over bed table and bed controls, without removing the gloves or performing hand hygiene. The CNA confirmed awareness of the enhanced barrier precautions but acknowledged not following them, including failing to don a gown and not performing hand hygiene before handling clean items. Facility policies required the use of both gown and gloves for high-contact care and specified hand hygiene after glove removal, but did not provide instructions for handling soiled linens and briefs after removal.