Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control protocols during incontinent care for a male resident with multiple complex medical conditions, including paraplegia, contractures, chronic respiratory failure, a gastrostomy tube, and an IV line. The resident was care planned for Enhanced Barrier Precautions (EBP) due to wounds and indwelling medical devices, with specific interventions requiring the use of gloves and gowns during high-contact care activities and education on proper PPE and hand hygiene. The resident was also frequently incontinent of urine and bowel and required substantial assistance with toileting hygiene. During an observation, the CNA entered the resident's room, which had signage indicating EBP and the need for gown and gloves. The CNA only donned gloves and did not wear a gown as required. While providing incontinent care, the CNA did not thoroughly clean the resident, omitting cleaning of the groin and penis, and cleaned the buttocks in a manner that did not follow the front-to-back technique outlined in facility policy. The CNA then placed a clean brief on the resident, disposed of soiled materials, and sanitized her hands. The CNA later acknowledged awareness of the correct procedures for PPE use and perineal care but did not follow them during the observed care. Interviews with the CNA and the Director of Nursing (DON) confirmed that the CNA had received training on proper resident care, including infection control and incontinent care procedures. Facility policies reviewed specified the need for thorough perineal cleaning and the use of both gown and gloves for residents on EBP during high-contact care activities. The failure to adhere to these protocols was directly observed and documented by surveyors.