Failure to Follow Infection Control and Hand Hygiene During Incontinent Care
Penalty
Summary
Certified Nursing Assistant (CNA) B failed to follow proper infection control and hand hygiene procedures while providing incontinent and catheter care to a male resident with a history of septic arthritis and a compromised immune system. During the observed care, CNA B did not change gloves or perform hand hygiene after removing a soiled brief and before applying a clean one, despite facility policy and the resident's care plan requiring these steps to prevent infection. Both CNA B and another CNA initially washed their hands and donned personal protective equipment, but CNA B continued to use the same gloves throughout the entire process, only removing them and washing hands after care was completed. Interviews with staff revealed that they were aware of the correct procedures, including the need to change gloves and perform hand hygiene when moving from dirty to clean tasks, but CNA B acknowledged not following these protocols during the observed care. The facility's infection control policy, revised in June 2024, requires standard precautions for all residents, including proper hand hygiene and glove changes to prevent cross-contamination. The failure to adhere to these procedures was confirmed through observation, staff interviews, and record review.