Failure to Maintain Infection Control During Incontinence Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to maintain proper infection control procedures during incontinence care for a resident with multiple diagnoses, including congestive heart failure, morbid obesity, diabetes, and erythema intertrigo. The resident was dependent on staff for most activities of daily living and was always incontinent of bowel and occasionally incontinent of urine. During observed care, the CNA placed soiled washcloths and towels directly on the bed, reused washcloths for different areas, and did not follow the facility's perineal care policy, which requires separate cloths and specific cleaning directions to prevent cross-contamination. The CNA was observed removing gloves, washing hands over the washcloths in the sink, and then reapplying gloves multiple times throughout the care process, but continued to use the same washcloths for different body areas. The CNA confirmed in an interview that proper infection control procedures were not followed. The facility's policy specifically instructs not to use the same cloth or water to clean the urethra or labia and to follow a front-to-back cleaning method, which was not adhered to during the observed care.