Infection Control Lapse During Incontinence Care
Penalty
Summary
During incontinence care for a resident with multiple diagnoses including diabetes mellitus type II, morbid obesity, depression, and chronic obstructive pulmonary disease, a Certified Nursing Assistant (CNA) failed to follow proper infection control practices. The resident, who was cognitively intact and dependent on staff for bed mobility, transfers, and toileting hygiene, was observed lying in bed when the CNA donned personal protective equipment and began care. The CNA removed the resident's incontinence product, cleansed the peri area, and then removed a soiled bordered dressing from the resident's left buttock, revealing a shallow open area. The CNA continued to cleanse the resident, using wipes to clean stool from both the anal area and the open wound, sometimes using the same wipe for both areas before disposal. The CNA did not perform hand hygiene immediately after providing care and before leaving the resident's room, instead applying hand sanitizer only after returning from disposing of soiled items in the utility room. The CNA confirmed during an interview that she had removed the dressing, which was not her responsibility, and acknowledged not performing hand hygiene at the appropriate time. The Director of Nursing confirmed that CNAs are expected to provide incontinence care but not to remove dressings, and that hand hygiene should be performed immediately after care and before leaving the resident's room. Facility policy also requires thorough cleansing and hand hygiene after incontinence care, which was not followed in this instance.