Failure to Follow Infection Control and Perineal Care Protocols
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by a certified nursing assistant (CNA) not performing hand hygiene before providing perineal care to a resident. During an observation, the CNA entered the resident's room, donned clean gloves without first washing her hands, and proceeded to provide perineal care. The CNA cleaned the female resident's perineal area from back to front, contrary to professional standards and facility policy, which require cleaning from front to back. The CNA also touched the trash can with gloved hands and then handled a clean brief without changing gloves, only removing gloves and washing hands after completing care. The resident involved was a cognitively intact female with a history of arthritis, hypotension, urinary tract infections, anxiety, and asthma, and was care planned for bowel incontinence. Facility policy and the director of nursing (DON) both confirmed that staff are expected to perform hand hygiene before and after care, and to clean from front to back during perineal care. The CNA acknowledged awareness of these standards but stated she forgot to perform hand hygiene and had no reason for cleaning from back to front. The facility's policies on perineal care and infection control were reviewed and found to be consistent with professional standards.