Failure to Follow Proper Incontinent Care and Hand Hygiene Protocols
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide appropriate incontinent care to a female resident with severe cognitive impairment, chronic kidney disease, and a history of clostridium difficile infection and bacteremia. During observed care, the CNAs did not follow proper hand hygiene protocols, as they repeatedly changed gloves without sanitizing their hands in between glove changes. One CNA also failed to change gloves or perform hand hygiene after touching soiled linen. Additionally, the care was not performed in the correct order, as barrier cream was applied to the buttocks before the vaginal area, contrary to facility policy and infection prevention standards. Interviews with the CNAs revealed a lack of understanding regarding the need for hand hygiene between glove changes, despite recent training. The nursing supervisor and DON confirmed that staff are expected to sanitize hands between glove changes and after contact with soiled items. Review of the facility's policy corroborated these requirements, specifying hand washing after removing soiled gloves and before donning new ones. Requested documentation of the CNAs' competencies or training was not provided prior to the survey exit.