Failure to Follow Infection Control Protocol During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinent care for a female resident with dementia and severely impaired cognition. The resident required substantial assistance with all activities of daily living and was always incontinent of bowel and bladder. During care, after cleaning the resident's pubic/groin and rectal areas, the CNA did not change gloves before placing a clean brief and applying barrier cream. Additionally, the CNA did not perform hand hygiene between glove changes, instead donning new gloves without using hand sanitizer or washing hands. Interviews with the CNA and facility leadership confirmed that the expected protocol was not followed, as staff are required to change gloves when moving from dirty to clean tasks and to perform hand hygiene between glove changes. Facility policy also specifies that gloves should be removed and hand hygiene performed before reclothing the resident. The failure to adhere to these procedures was observed directly and acknowledged by the staff involved.