Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and personal protective equipment (PPE) practices during incontinent care for a resident. Two CNAs provided care without washing their hands and donned gloves taken from their uniform pockets, rather than from a clean supply. Throughout the care process, the CNAs used the same gloves for multiple tasks, including cleaning the resident and applying a clean incontinent brief, which resulted in cross-contamination. Additionally, one CNA used peri wipes instead of disinfectant wipes to clean urine from the resident's air mattress, failing to properly disinfect the surface. The resident involved was a female with significant medical conditions, including morbid obesity, diabetes mellitus, hypertension, and a history of cerebral infarction. She required total assistance with activities of daily living and was frequently incontinent of bladder and bowel. Her care plan specified prompt changing and the use of protective barriers, but the observed care did not adhere to infection control protocols outlined in facility policy. Interviews with the CNAs, LVN, DON, and Administrator confirmed that the staff did not follow established procedures for hand hygiene and glove use, and acknowledged the risk of cross-contamination from their actions. Facility policies required hand hygiene before donning gloves and after glove removal, and specified the use of disinfectant wipes for cleaning contaminated surfaces, but these protocols were not followed during the observed incident.