Failure to Maintain Infection Control During Incontinence Care and Mechanical Lift Transfer
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow infection control protocols during incontinence care and a mechanical lift transfer for a resident with chronic kidney disease, anxiety disorder, and unsteadiness on feet. The resident was fully dependent on staff for incontinence care and transfers and was always incontinent of bladder and bowel. During the observed care, the CNA initially used hand sanitizer but, upon finding the glove box empty, left the room, touched various surfaces, and returned with new gloves without performing hand hygiene. The CNA then provided perineal care, handled multiple items, applied barrier cream, and changed the resident's brief, all while wearing the same pair of gloves. The CNA continued to use the same soiled gloves to handle the sling pads, operate the Hoyer lift, and transfer the resident to a wheelchair. After completing the care, the CNA removed only one glove, used hand sanitizer on the ungloved hand, and exited the room with the other glove still on, later removing it in the utility room. The CNA confirmed during an interview that proper hand hygiene and glove usage were not followed. Facility policy and staff interviews confirmed that hand hygiene should be performed before and after glove use, after perineal care, and before and after each procedure, which was not adhered to during this incident.