Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA entered the resident's room, performed hand hygiene, and donned gloves that had been carried in her uniform pocket. During the care, the CNA's gloves became soiled with feces, and instead of changing gloves and performing hand hygiene before proceeding to clean areas, she wiped the gloves with disposable wipes and continued with the care. The CNA then used the same gloves to handle clean items, such as a new brief and underpad, and to reposition the resident, only removing the gloves and performing hand hygiene after completing all tasks. The resident involved was an elderly female with diagnoses including type 2 diabetes mellitus, cerebrovascular accident, and weakness, and was always incontinent of bowel and bladder with moderately impaired cognition. The facility's perineal care policy required staff to remove gloves and perform hand hygiene before reapplying new gloves when moving from dirty to clean tasks. Both the CNA and the Director of Nursing (DON) acknowledged during interviews that gloves should not be carried in pockets and that proper glove changes and hand hygiene are necessary to prevent cross-contamination and infection.