Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow established infection prevention and control procedures while providing incontinent care to a resident with multiple risk factors, including an indwelling catheter, PEG tube, and a stage 3 pressure ulcer. The CNA did not don a personal protective equipment (PPE) gown prior to starting care, despite facility policy and the resident's Enhanced Barrier Precautions (EBP) status requiring both gown and gloves for high-contact care activities. The CNA only applied the gown after beginning care and being reminded, which was confirmed by both the assistant director of nursing (ADON) and the CNA during interviews. During the care episode, the CNA also failed to consistently perform hand hygiene between glove changes, only washing hands after every second glove change and not using hand sanitizer between other glove changes as required by facility policy. The CNA was observed to use one wipe per swipe initially, but then began folding and reusing wipes for multiple swipes, contrary to the facility's policy that specifies using a clean portion of the wipe for each cleansing motion and disposing of wipes after use, especially when soiled. The CNA's actions were inconsistent with both the facility's infection control and incontinent care policies, which were reviewed and confirmed by the director of nursing (DON) and other staff. Interviews with the CNA, LVN, ADON, and DON revealed that all staff had received training on infection control, EBP, and proper incontinent care procedures, including the use of PPE and hand hygiene. The CNA acknowledged forgetting to put on the gown due to nervousness and demonstrated confusion about the correct frequency of hand hygiene between glove changes. The DON and ADON confirmed that the observed practices did not align with facility policy and that proper PPE and hand hygiene are essential to prevent the spread of infection, especially for residents on EBP.