Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to provide perineal care in accordance with infection prevention and control protocols for one of two residents observed. During the observation, a CNA gathered supplies and entered the resident's room, which was under Enhanced Barrier Precautions (EBP), without donning a gown as required. The CNA placed supplies directly on the table without a barrier, did not perform hand hygiene before, during, or after care, and did not change gloves during the procedure. The CNA also failed to separate the labia to clean each side and the center individually, did not clean the rectal area, and placed soiled wipes and briefs on the bed instead of in a designated bag. After completing care, the CNA removed gloves and exited the room without washing or sanitizing hands. Interviews with facility staff, including the CNA, RN Unit Manager, Executive Director, DON, and Infection Preventionist, confirmed that the CNA did not follow established protocols for EBP, hand hygiene, and perineal care. Staff acknowledged that the CNA's actions constituted cross-contamination and did not meet the facility's expectations for infection control. The CNA admitted to not wearing a gown, not washing hands, and not following proper perineal care procedures, attributing the lapse to nervousness and oversight. The resident involved had a history of significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview. Facility records and policy reviews indicated that staff were trained and expected to follow EBP and hand hygiene protocols, but these were not adhered to during the observed incident.