Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during incontinent care for one resident. During observation, two CNAs performed perineal care without adhering to established hand hygiene and glove-changing protocols. Specifically, after cleaning the resident's groin and peri-anal areas, one CNA did not remove soiled gloves or perform hand hygiene before handling clean items such as a new brief and barrier cream. The same CNA only changed one glove and continued to use the other, which had been exposed to contaminated areas, to touch clean items and bedding. Both CNAs failed to perform hand hygiene before leaving the resident's room, instead using hand sanitizer only after exiting or not at all in the immediate area. The resident involved was a female with multiple diagnoses, including acute respiratory failure, pneumonia, heart failure, cellulitis, and morbid obesity. She was always incontinent of urine and frequently incontinent of bowel, requiring staff assistance for toileting and hygiene. The care plan indicated a need for substantial assistance with personal hygiene and emphasized maintaining the highest level of function in daily activities. Interviews with staff revealed inconsistent understanding and application of infection control protocols. One CNA believed it was acceptable to use a glove that appeared clean to handle clean items, while another CNA acknowledged the risk of cross-contamination and the importance of changing gloves and performing hand hygiene. The DON confirmed that staff were expected to follow proper procedures, including changing gloves and sanitizing hands at appropriate times, and that staff had received in-service training on these protocols. Facility policies reviewed supported the need for strict hand hygiene and glove use during resident care.