Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to follow proper infection prevention and control protocols while providing incontinent care to a resident with severe cognitive impairment and total dependence for activities of daily living. During care, one CNA touched the bed remote with gloved hands and another touched the privacy curtain with bare hands, but neither changed gloves or performed hand hygiene before starting direct care. Additionally, one CNA changed gloves multiple times during the care process but did not sanitize or wash hands between glove changes, contrary to facility policy and training. Both CNAs acknowledged during interviews that the bed remote and privacy curtain were considered dirty and admitted they did not realize the need to change gloves and sanitize hands before providing care. The Director of Nursing confirmed that staff are expected to change gloves and perform hand hygiene prior to care and between glove changes, as outlined in facility policy. Competency checks for both CNAs indicated prior demonstration of proper handwashing and incontinent care, and the facility's policy required hand hygiene before donning and after doffing gloves.