Failure to Maintain Infection Control During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed during incontinent care for a resident. During the observation, two CNAs performed peri-care for a female resident with a history of metabolic encephalopathy and cystitis, who was cognitively intact and had a care plan addressing incontinence. Neither CNA washed their hands or used hand sanitizer at any point during the peri-care process, and one CNA was observed folding and reusing a wipe before discarding it, despite the presence of a bowel movement. Interviews with the involved CNA revealed an awareness of the failure to follow proper peri-care and hand hygiene protocols, citing the absence of hand gel in the room as a reason for not performing hand hygiene between glove changes and after care. The CNA acknowledged the potential for cross-contamination and bacterial transfer. The DON confirmed that staff are expected to follow facility policy, which requires handwashing after glove removal and after providing care, and stated that staff are regularly monitored. Facility policy on incontinent care specifically outlines the need for hand hygiene at key points during the procedure, which was not followed in this instance.