Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
A deficiency was identified when a Certified Nurse's Aide (CNA) failed to follow standard infection prevention and control protocols during the provision of morning care for two residents. The CNA was observed assisting one resident with a bed bath, using gloved hands to wash the resident and then using the same soiled gloves to handle the resident's personal items, such as a phone, and to touch various surfaces in the room, including pillows that had been on the floor and the door knobs. The CNA also used the same soiled gloves to pick up clean linen from the hallway linen cart and to handle clean clothing and apply lotion to the resident, without performing any hand hygiene or changing gloves throughout the entire care episode. The CNA continued to use the same soiled gloves to handle soiled linens, which were placed on the bare floor, and to interact with the roommate's belongings and bed linens. At no point during the observed care did the CNA remove the soiled gloves or perform hand hygiene, despite moving between different residents' belongings and clean and soiled items. The CNA acknowledged after the observation that gloves should have been changed and hand hygiene performed, and that soiled linens should have been contained in plastic bags rather than placed on the floor. Interviews with the Infection Control Nurse and the Director of Nursing confirmed that facility policy requires staff to perform hand hygiene before and after resident contact, change gloves between tasks, and avoid touching clean linen carts or moving between residents with soiled gloves. The facility's infection control policies, reviewed and current, specify these requirements for all staff to prevent the spread of infection. The observed failure to adhere to these protocols affected the two residents involved and had the potential to impact all residents on the floor.