Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to adhere to proper infection prevention and control practices while providing incontinence care to an 86-year-old male resident with a history of COVID-19, acute upper respiratory infection, constipation, and mobility issues. During the observed care, CNA A initially washed her hands and donned gloves, but after removing a soiled brief and cleaning the resident, she continued to handle clean items, such as a new brief, without changing her visibly soiled gloves or performing hand hygiene. She only washed her hands before exiting the resident's room, contrary to the facility's hand hygiene policy, which requires hand hygiene after removing gloves and before handling clean items. The resident was dependent on staff for most activities of daily living and was frequently incontinent of bowel and bladder. CNA A acknowledged during an interview that she did not follow standard precautions and recognized the risk of cross-contamination by mixing clean and dirty tasks without proper glove changes or hand hygiene. The Director of Nursing confirmed expectations for staff to follow infection control protocols, including hand washing and glove changes as needed during care, and noted that staff receive regular infection control training.