Failure to Follow Infection Control Protocol During Perineal Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow proper infection prevention and control procedures during perineal care for a resident with severe cognitive impairment, hemiplegia, hemiparesis, and incontinence. The CNA performed hand hygiene and donned clean gloves before care, but then touched multiple surfaces in the resident's environment, including the call light remote, blankets, and sheets, without removing her gloves or performing hand hygiene again before starting incontinent care. This sequence of actions did not align with infection control best practices, as the gloves became potentially contaminated after contact with the resident's surroundings. The resident involved was dependent on staff for most activities of daily living and was at risk for skin breakdown and urinary tract infections due to incontinence. The CNA acknowledged during an interview that she should have removed her gloves and performed hand hygiene after touching the resident's environment and before providing direct care. The facility's Director of Nursing confirmed that the expected procedure, in line with CDC guidelines, was not followed. Facility records showed that the CNA had recently completed training on infection prevention and hand hygiene, and that the facility's infection control policy did not specifically detail hand hygiene requirements during incontinent care.