Failure to Follow Infection Control Protocols During Peri-Care
Penalty
Summary
During the provision of peri-care for one resident, two Certified Nursing Assistants (CNAs) failed to adhere to proper infection prevention and control protocols as outlined in the facility's policy. The CNAs donned gowns and gloves before entering the resident's room and proceeded to provide care, including washing the resident's underarms, breasts, and peri-area, as well as handling soiled linens and briefs. Throughout the care process, the CNAs repeatedly touched the resident and various items in the room with soiled gloves, including after cleaning areas contaminated with stool. They did not change gloves or perform hand hygiene between tasks as required by standard precautions and the facility's infection control policy. The resident involved was dependent on staff for toileting and required partial to moderate assistance with hygiene, but had intact cognition as indicated by a BIMS score of 15 out of 15. The CNAs themselves confirmed during an interview that they had touched the resident and multiple items in the room with soiled gloves and acknowledged that they should have changed gloves and washed hands after providing peri-care. The facility's infection prevention and control policy required hand hygiene and appropriate use of personal protective equipment, but a specific hand hygiene policy was not provided during the survey.