Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during incontinence care for a resident. The CNA donned clean gloves and a gown after using hand gel in the hallway, then proceeded to provide incontinence care, including cleaning the resident's pubic, genital, and rectal areas. Throughout the process, the CNA did not change soiled gloves or perform hand hygiene between tasks, even after handling soiled materials and repositioning the resident. The CNA continued to assist with repositioning and dressing the resident while wearing soiled gloves, and only removed the gloves and gown at the end of care, washing hands afterward. Additionally, after removing dirty gloves, the CNA did not perform hand hygiene before donning new gloves and continued to assist with the resident's clothing and linens. Interviews with the CNA and the Director of Nursing (DON) confirmed that the facility's expectation and policy require hand hygiene before and after care, and glove changes after removing dirty gloves. The CNA acknowledged awareness of these procedures but did not follow them during the observed care, attributing the lapse to nervousness and distraction. Review of facility policies and recent in-service training indicated that the CNA had been trained on proper hand hygiene and infection control practices, including the requirement to wash hands after removing gloves and before direct contact with residents.