Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper glove use and hand hygiene during incontinent care for one resident. During an observation, a CNA performed perineal care for a resident who was always incontinent of urine and frequently incontinent of bowel, and who had severe cognitive impairment. The CNA's gloved hands came into contact with the resident's skin while cleaning the perineal area, but the CNA did not change gloves or wash hands before fastening a clean brief and assisting the resident with pants, despite facility policy requiring glove removal and hand hygiene after contamination. Interviews with the CNA, the Administrator, and the DON confirmed that gloves should have been changed and hands washed after contamination to prevent cross contamination. Review of the resident's care plan and the facility's infection control and perineal care policies further supported the requirement for proper glove use and hand hygiene. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in the facility's infection control practices.