Failure to Follow Infection Control Protocol During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA did not change contaminated gloves or perform hand hygiene before handling clean linen after cleaning the resident, despite being trained to do so. This lapse was observed during incontinence care, where the CNA transitioned from a dirty to a clean task without changing gloves or washing hands, contrary to facility policy and infection control guidelines. The resident involved was a cognitively intact female with a history of chronic respiratory failure with hypoxia, end stage renal disease, and type 2 diabetes, and was frequently incontinent of bowel and bladder. The resident's care plan required peri-care after each incontinent episode. The facility's hand-washing policy specified hand hygiene after contact with body fluids or potentially contaminated items, which was not followed in this instance.