Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection control procedures while providing incontinent care to a resident with multiple medical conditions, including Wernicke's encephalopathy, dysphagia, hypothyroidism, hyperlipidemia, hypertension, and asthma. The resident was moderately cognitively impaired, always incontinent of bladder and bowel, and required total assistance with activities of daily living. During the observed care, the CNA washed her hands but then touched the room door with bare hands, did not sanitize her hands before donning gloves, and began care. Throughout the process, the CNA changed gloves multiple times without sanitizing her hands between glove changes. After cleaning the resident's buttocks and removing soiled briefs, the CNA failed to change gloves or sanitize hands before handling clean briefs. Interviews with the CNA and the Director of Nursing (DON) confirmed that the CNA did not follow established infection control protocols, including hand hygiene before gloving and between glove changes, as well as when transitioning from soiled to clean tasks. The DON acknowledged that the room door is considered a contaminated surface and that staff are required to sanitize hands before putting on gloves and between glove changes. Facility policy reviewed indicated that standard precautions, including proper hand hygiene and use of personal protective equipment (PPE), are required for all resident care activities.