Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
During an observation of incontinent care for a resident with a history of frontal lobe and executive function deficit following cerebral infarction, two CNAs failed to maintain proper infection control practices. After cleaning the resident's abdominal folds and peri area, including removal of fecal matter and a soiled brief, CNA #1 did not change gloves before placing a new pad under the resident. CNA #2 also handled both soiled and clean items without changing gloves. The process continued with the same gloves until the brief tab tore, at which point CNA #1 removed gloves and left the room to retrieve a new brief. Both CNAs acknowledged during interviews that gloves should have been changed between dirty and clean tasks, and the DON confirmed this protocol.