Failure to Follow Infection Control Procedures During Incontinence Care
Penalty
Summary
During an observation of incontinence care, a certified nurse assistant (CNA) failed to follow proper infection control procedures while providing personal care to a resident with multiple diagnoses, including neurogenic bladder, urinary retention, and impaired mobility. The CNA performed hand hygiene before entering the room and donned gloves, but after removing soiled gloves, she handled a walkie-talkie and donned new gloves from her pocket without performing hand hygiene. The CNA continued to provide care, including cleaning the resident and repositioning, without changing gloves or performing hand hygiene between tasks, even when visible fecal matter was present on the gloves. The resident involved was cognitively intact but dependent on staff for toileting and was frequently incontinent of bowel and bladder. Facility policies required hand hygiene after removing gloves and after handling potentially contaminated objects, but these procedures were not followed during the observed care. Both the CNA and the Director of Nursing confirmed that hand hygiene should have been performed after doffing soiled gloves and before donning new ones, which did not occur during the incident.