Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
During an observation of incontinence care for Resident #4, who had diagnoses including dementia, major depression, chronic kidney disease, and psychotic disorder, two CNAs failed to follow proper infection control procedures. Resident #4 was dependent on staff for toileting and was incontinent of bowel and bladder. The CNAs donned gloves and positioned the resident for care, but one CNA removed a soiled brief and threw it on the floor instead of placing it in the appropriate receptacle. The brief was later picked up from the floor and disposed of in the trash can. Both CNAs continued with peri care and repositioning the resident without performing hand hygiene after glove removal, and did not change gloves or wash hands before using a mechanical lift or returning the resident to the dining area. Interviews with the CNAs confirmed that hand hygiene was not performed during or after the care, and that the soiled brief was improperly discarded. The Director of Nursing verified that staff are required to wash hands after removing dirty gloves and that soiled items should not be placed on the floor. Review of facility policy also indicated that hand hygiene should be performed at multiple points during incontinence care and that disposable items must be discarded in designated containers.