Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection control procedures while providing incontinence care to a 73-year-old female resident with a history of urinary tract infection, bacteremia, abdominal pain, pancreatic cancer, and muscle weakness. The resident required moderate assistance with activities of daily living and was always incontinent of bowel and bladder. During observed care, CNA A did not wash her hands before donning gloves, put on gloves in the hallway, and proceeded to remove a soiled brief and clean the resident without changing gloves, even when the gloves became visibly soiled with urine and fecal matter. CNA A also failed to perform hand hygiene or change gloves before retrieving and applying a clean brief, and did not wash her hands after removing gloves or before exiting the resident's room. In interviews, CNA A acknowledged awareness of the correct procedures, stating she should have washed her hands before starting care and changed gloves during care, but attributed her failure to not paying attention. The Director of Nursing (DON) confirmed that staff are expected to follow facility protocols, including hand washing and glove changes as needed, and that infection control training is provided annually. Review of the facility's hand hygiene policy confirmed the requirement for hand washing before care, glove changes as needed, and hand hygiene after glove removal.