Infection Control Lapse During Incontinence Care
Penalty
Summary
During incontinence care for Resident #42, who had diagnoses including cerebral palsy, high blood pressure, Alzheimer's disease, and a history of falls, staff failed to follow infection control standards. The resident was cognitively impaired, fully dependent on staff for toileting, and always incontinent of bowel and bladder. Observation revealed that a Certified Nurse Aide (CNA) placed care supplies directly onto the bedside table without cleaning the surface or using a barrier. Additionally, after removing soiled gloves, the CNA retrieved additional supplies and donned new gloves without performing hand hygiene, contrary to the facility's hand hygiene policy, which requires hand hygiene immediately after glove removal. These findings were confirmed through staff interview and policy review.