Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
Staff failed to follow the facility's infection prevention and control program during perineal care for two residents with complex medical needs, including suprapubic catheters and pressure ulcers. Observations revealed that staff did not perform proper hand hygiene between glove changes, used double gloving instead of single gloves, and did not change gloves when moving between contaminated and clean body sites. In one instance, staff wiped the resident's genitals and buttocks without changing gloves or performing hand hygiene, and failed to apply a moisture barrier after care. Additionally, soiled incontinence pads were handled in a manner that could spread contamination, and catheter care was performed without appropriate handwashing or glove changes. For another resident, staff did not perform hand hygiene before donning gloves and handled catheter collection bags inappropriately by placing them in a trash can and then reusing them. Wash cloths for perineal care were placed on an unprotected chair, and staff touched soiled briefs and then their own hands without changing gloves. During perineal care, staff wiped fecal matter and then the resident's back with the same gloves, further violating infection control protocols. These actions were inconsistent with the facility's policies, which require handwashing at appropriate times, glove changes between contaminated and clean sites, and the use of protective barriers during care. Interviews with staff and management confirmed a lack of adherence to established infection control procedures. Staff admitted to not using basins with soap and water for catheter care, double gloving due to misunderstanding, and not following proper glove and hand hygiene protocols. Management acknowledged the deficiencies and described the correct procedures, indicating that staff actions during the observed care did not meet facility expectations or policy requirements.