Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of a CNA during incontinent care for a resident. The CNA did not perform hand hygiene before, during, or after providing care, and failed to change gloves between tasks. After completing care, the CNA transported soiled linen in her hands down the hallway instead of using a plastic bag, and only sanitized her hands after disposing of the linen. Additionally, the CNA removed a package of disposable wipes from the resident's room and placed them back on a cart in the hallway, contrary to infection control protocols. The resident involved was an elderly female with multiple diagnoses, including hemiplegia, hemiparesis, epilepsy, and incontinence, and was dependent on staff for toileting and personal hygiene. Facility records and staff interviews confirmed that the CNA was aware of the correct procedures but did not follow them during the observed care. Facility policies required hand hygiene before and after resident contact, proper handling of soiled linen, and that personal care items not be returned to common areas after use in resident rooms. These lapses were directly observed and confirmed through interviews and record review.