Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinent care for a resident. During an observation, two CNAs provided peri care to a resident with severe cognitive impairment, bowel and bladder incontinence, and multiple medical conditions including hypertensive chronic kidney disease and acute cystitis. While performing care, one CNA did not change gloves or wash hands after cleaning the resident's perineal area and before applying a clean brief, repositioning the resident, and handling bedding and pillows. The CNA only removed gloves and washed hands after completing all tasks and before exiting the room. Interviews with the involved CNAs, the ADON, DON, and Administrator confirmed that the expected practice was to change gloves and perform hand hygiene when moving from dirty to clean tasks during incontinent care. Record reviews showed that both CNAs had been trained and demonstrated proficiency in handwashing and perineal care according to facility policy, which also required glove removal and hand hygiene at appropriate steps. The failure to follow these procedures was directly observed and acknowledged by staff and leadership.