Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA D during incontinence care for two residents. CNA D was observed providing incontinence care to two female residents with significant medical histories, including hemiplegia, hypertension, heart failure, renal insufficiency, and severe cognitive impairment. Both residents were dependent on staff for toileting and hygiene, and their care plans included interventions to prevent skin breakdown and maintain skin integrity. During the observed care, CNA D performed hand hygiene before initial resident contact and donned gloves. However, he did not cleanse the peri area for either resident, only cleaning the abdominal folds and buttocks. He failed to change gloves or perform hand hygiene after handling soiled linens and before applying clean briefs and linens, using the same gloves throughout the process. One resident was noted to have a bowel movement, yet the same lapses in infection control were observed. CNA D later acknowledged forgetting to perform hand hygiene and peri care as required. Interviews with the LVN, ADON, and DON confirmed that CNA D did not follow expected infection control practices, including changing gloves and performing hand hygiene during and after care, and completing peri care before applying clean briefs. Facility policy and recent staff training records indicated that proper hand hygiene is required before and after resident contact, and after contact with soiled or contaminated articles. The observed failures were inconsistent with these policies and training.