Infection Control Lapses in Perineal Care and Equipment Sanitization
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for three residents, as evidenced by direct observations and staff interviews. In one instance, a certified nursing assistant (CNA) provided perineal care to a resident with severe cognitive impairment and incontinence, but handled a packet of wet wipes with soiled gloves during the cleaning process. The contaminated wipe packet was then saved at the resident's bedside, contrary to infection control protocols and the facility's own policy, which requires changing gloves if soiled and proper handling of supplies to prevent cross-contamination. Additionally, a medication aide (MA) was observed taking blood pressure readings for two residents with hypertension and other comorbidities, using the same blood pressure monitor without sanitizing it between uses. The aide did not clean the equipment until prompted by the investigator, despite acknowledging the importance of sanitizing medical equipment to prevent the spread of infection. The aide stated that she had received general infection control training but had not attended any in-services specifically focused on sanitizing medical equipment. Record reviews confirmed that the facility had policies in place for perineal care and infection prevention, including requirements for hand hygiene, glove use, and cleaning of reusable equipment. However, the observed practices by staff did not align with these policies, resulting in lapses that could facilitate the transmission of communicable diseases among residents. The deficiencies were identified through a combination of observation, interview, and review of facility records.