Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection prevention and control procedures during incontinent care for a male resident with multiple diagnoses, including PTSD, hypertension, diabetes mellitus, and renal insufficiency. The resident was alert, oriented, and required assistance for incontinence care. During the observed care, CNA A donned clean gloves and performed perineal and rectal cleaning but did not change soiled gloves or perform hand hygiene between tasks, despite handling soiled materials and repositioning the resident multiple times. The CNA continued to use the same soiled gloves to assist another staff member in repositioning the resident, pulled up a clean brief, and fastened it, all without changing gloves or washing hands until after leaving the resident's room. The facility's policies on perineal care and infection control require hand hygiene before and after care, as well as glove changes when gloves become soiled. CNA A acknowledged awareness of these procedures but did not follow them during the observed incident, attributing the lapse to being nervous and distracted. The Director of Nursing confirmed the expectation for hand hygiene and glove changes as outlined in facility policy. Review of training records indicated that CNA A had previously attended in-service training on hand hygiene and incontinent care.