Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed among three CNAs during incontinent care for two residents. Specifically, CNA-B did not change gloves between cleaning a resident and adjusting the resident's nasal cannula, potentially contaminating the oxygen tubing. Both CNA-A and CNA-B acknowledged during interviews that gloves should have been changed after cleaning the resident and before applying a clean brief, and that hand hygiene should have been performed prior to assisting with the oxygen tubing. For another resident, CNA-C did not change gloves between removing a soiled brief and applying a clean one, believing that glove changes were unnecessary if there was no bowel movement. Interviews with nursing staff, including an RN and the Director of Operations, confirmed that gloves should be changed and hand hygiene performed between dirty and clean tasks during peri-care. The Director of Nursing (DON) also stated that gloves should be changed if any fecal matter is present before putting on a clean brief. Both residents involved had significant medical histories, including muscle wasting, lack of coordination, and incontinence, with one resident being cognitively intact and the other severely impaired. The facility's own policy required glove changes and hand hygiene before and after glove use, but these procedures were not followed during the observed care. The DON acknowledged that insufficient monitoring and possibly inadequate staff training contributed to the failure to adhere to infection control protocols.