Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during the provision of incontinent care to one resident. During an observed care episode, a certified nursing assistant (CNA) did not change gloves or perform hand hygiene when transitioning from dirty to clean tasks. The CNA also placed a clean brief on wet, soiled linens, contrary to infection control protocols. Both CNAs involved donned gowns and gloves as required for Enhanced Barrier Precautions, but the sequence of glove changes and hand hygiene was not followed as per facility policy. The resident involved had a history of cerebral infarction, type 2 diabetes, major depressive disorder, and hypertension, and was dependent on staff for toileting hygiene due to incontinence. The care plan required staff to check and assist the resident every two hours and to clean the perineal area after each episode of incontinence. During the observed care, the CNA performed perineal cleaning and applied barrier cream but failed to change gloves or sanitize hands between tasks, and placed clean items on soiled surfaces. Interviews with the CNA, Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator confirmed that the expected practice was to perform hand hygiene before care, between dirty and clean tasks, after glove removal, and at the end of care. The facility's policy also specified that glove use does not replace hand hygiene and that clean items should not be placed on dirty linens. The CNA acknowledged the lapse in protocol and attributed it to nervousness during observation.