Failure to Follow Proper Incontinent Care and Infection Control Procedures
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate incontinent care and infection control for a resident who was always incontinent of bowel and bladder and had a history of hemiplegia and hemiparesis. During observed care, a CNA cleaned the resident's buttock and anal area, then handled a clean brief with the same soiled gloves, placing it on the bed. Both the CNA and a student aide then assisted the resident, removed their gloves, but did not perform hand hygiene before donning new gloves. The student aide applied barrier cream, again changed gloves without hand hygiene. Both staff members acknowledged during interviews that they had not followed proper hand hygiene protocols and recognized the risk of cross contamination. The facility's policy required hand hygiene before and after glove use and specified that perineal care should be performed from clean to dirty areas to avoid contamination. The DON confirmed that staff were expected to wash or sanitize hands between glove changes and when moving from dirty to clean areas. Audits showed both staff had previously satisfied requirements for hand washing and perineal care. The failure to follow these procedures was directly observed and confirmed by staff and the DON, constituting a deficiency in infection control and incontinent care practices.