Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices during incontinent care for a resident with severe cognitive impairment, multiple chronic conditions, and total incontinence. The CNA, after performing perineal care, did not change gloves or perform hand hygiene before handling clean items such as the resident's clothing, clean brief, clean incontinent pad, bedding, and bed remote. This sequence of actions was observed directly and confirmed through interviews with staff, who acknowledged that the CNA did not adhere to established protocols for glove use and hand hygiene. The resident involved was an elderly individual with diagnoses including dementia, heart disease, diabetes, hemiplegia, and cerebrovascular disease, and was always incontinent of urine and bowel. The care plan identified a risk for skin breakdown due to incontinence. During the observed care episode, the CNA used the same gloved hands that had been in contact with soiled areas to touch the resident's shoulder, hip, clothing, bedding, and other clean items, and also failed to perform hand hygiene after removing soiled gloves and before donning new ones. Interviews with another CNA, the Director of Nursing (DON), and the Administrator confirmed that the expected practice was to change gloves and perform hand hygiene when moving from a dirty to a clean area, and before handling clean items. Facility policies reviewed also required hand hygiene and glove changes at appropriate points during resident care. The CNA's failure to follow these procedures was acknowledged by the staff involved and was documented as not meeting the facility's infection control standards.