Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during incontinent care for a female resident with a history of metabolic encephalopathy and cystitis. During peri-care, neither CNA performed hand hygiene at any point, including after removing soiled gloves and after completing care, despite the presence of a bowel movement. One CNA was observed folding and reusing a wipe before discarding it. Both CNAs failed to follow the facility's policy, which requires handwashing after glove removal and after providing care. Interviews confirmed that the CNA was aware of the failure to perform proper peri-care and hand hygiene, attributing the lapse to not having hand sanitizer in the room. The CNA had received infection control and peri-care training three months prior. The DON acknowledged that staff should have followed policy and that the facility regularly monitors staff, but suggested the CNA's performance may have been affected by being observed by surveyors. The facility's policy on incontinent care clearly outlines the required steps for hand hygiene and glove use, which were not followed during the observed incident.