Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
During an observation of incontinence care for Resident #69, a CNA gathered supplies, performed hand hygiene, and donned gloves before removing the resident's brief and providing care. After cleaning the resident and applying a clean brief, the CNA continued to reposition the resident and adjust the bed by touching the remote control with the same gloves that had been used during incontinence care. The CNA then removed her gloves, performed hand hygiene, and exited the room. An interview with the CNA revealed that she did not believe it was necessary to change gloves while repositioning the resident or adjusting the bed, as the gloves were not visibly soiled. Review of the facility's incontinence care policy indicated that gloves should be disposed of and hand hygiene performed after cleaning and drying the resident, before continuing with other tasks. This practice was not followed, resulting in a failure to adhere to proper infection control procedures for a resident who was dependent on staff for all activities of daily living and had multiple diagnoses, including impaired cognition and incontinence.