Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
Certified Nursing Assistant (CNA) A failed to follow proper infection control procedures while providing incontinence care to a female resident with a history of methicillin susceptible and resistant staphylococcus aureus infections, bacteremia, and breast cancer. During the observed care, CNA A washed her hands before donning gloves and removed a soiled brief, but did not change gloves or perform hand hygiene after cleaning the resident and before handling a clean brief. The gloves were visibly soiled with urine, and CNA A continued care and handled clean items without changing gloves or washing hands. She only removed her gloves and washed her hands after completing care and handling trash. In an interview, CNA A acknowledged she should have changed gloves before handling the clean brief and recognized the risk of cross-contamination, attributing her lapse to being nervous. The Director of Nursing (DON) confirmed that infection control training is provided monthly and that staff are expected to follow standard precautions, including hand hygiene and glove changes. The facility's infection control policy requires adherence to standard precautions and proper hand hygiene, which were not followed during the observed incident.