Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices during incontinence care for a resident. The CNA washed her hands before donning gloves and removed a soiled brief from the resident, who was a 78-year-old female with age-related debility, muscle weakness, and frequent incontinence. However, after cleaning the resident, the CNA did not change her gloves or perform hand hygiene before handling a clean brief and placing it under the resident. The gloves were visibly soiled with urine, and the CNA continued to handle clean items and dispose of waste without changing gloves or performing hand hygiene until the end of care. The resident's care plan required maintaining cleanliness and being odor-free, and the facility's infection control policy mandated hand hygiene and glove changes according to standard precautions. During interviews, the CNA acknowledged the lapse in infection control, attributing it to nervousness, and the DON confirmed expectations for staff to follow standard precautions. The facility's policy and staff training requirements were reviewed, but the observed actions did not align with established infection control protocols.