Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
During an observation of incontinent care provided to Resident #6, a CNA failed to change gloves or perform hand hygiene after cleaning the resident's buttocks and before handling clean items, including a draw sheet and brief. The CNA acknowledged during an interview that she forgot to change her gloves before touching the clean items and stated she had received infection control training within the past year. The Director of Nursing (DON) confirmed that staff are expected to change gloves and sanitize hands prior to handling clean items to prevent cross-contamination and infection. Resident #6 had a history of Alzheimer's disease, type 2 diabetes, hyperlipidemia, vascular dementia, anxiety, chronic kidney disease, major depressive disorder, and non-Hodgkin lymphoma. The resident was always incontinent of bowel and bladder and required extensive assistance with activities of daily living. The facility's policy required hand hygiene in accordance with established procedures, and the CNA had previously passed a competency check for incontinent care. However, the DON revealed there was no additional policy regarding hand hygiene or glove use during care.