Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
Staff failed to follow established infection control protocols during personal care for two residents who were dependent on staff for activities of daily living and incontinent of bowel and bladder. In both cases, certified nurse aides (CNAs) did not perform hand hygiene before beginning care, donned gloves taken from their pockets, and proceeded to provide care without changing gloves or washing hands between clean and dirty tasks. During care, CNAs handled soiled briefs, performed peri care, and then touched clean supplies, resident bedding, and room equipment without removing soiled gloves or performing hand hygiene. In one instance, a CNA also used a cell phone and handled other items in the resident's environment while wearing the same gloves used for personal care. Interviews with staff confirmed knowledge of the facility's hand hygiene policy, which requires handwashing before and after resident care and glove changes between clean and dirty tasks. However, observations and video evidence showed repeated failures to adhere to these protocols, including not removing gloves or washing hands after providing peri care and before touching other surfaces or equipment. The facility's policy emphasized the importance of hand hygiene to prevent the spread of healthcare-associated infections, but these procedures were not followed during the observed care episodes.