Failure to Prevent Cross Contamination During Incontinence Care
Penalty
Summary
During incontinence care for one resident, a Certified Nursing Assistant (CNA) failed to follow proper infection control procedures as outlined in the facility's Perineal Care policy. The CNA, after cleaning the resident's vaginal area in a front to back motion, turned the resident to cleanse the buttocks but did not change gloves before applying a clean brief and subsequently cleaning the vaginal area again. This sequence of actions resulted in the use of contaminated gloves to clean the resident's vaginal area after having cleaned the buttocks, which is contrary to the facility's policy requiring glove changes when moving from soiled to clean areas. The resident involved had moderate cognitive impairment, was always incontinent of bowel and bladder, and was dependent on staff for toileting hygiene. Medical records indicated the resident had a recent history of urinary tract infection (UTI) with urine cultures showing significant growth of Klebsiella Oxytoca ESBL and Escherichia Coli, and was receiving antibiotic treatment. The CNA confirmed during interview that gloves should have been changed between cleaning the buttocks and the vaginal area, acknowledging the lapse in infection control practice.