Failure to Prevent Cross Contamination During Incontinence Care
Penalty
Summary
The deficiency involves failure to prevent cross contamination during incontinence care for one resident who was cognitively intact and required assistance with toileting and personal hygiene, as documented on the resident’s MDS. During observed incontinence care, the CNAs did not disinfect the bedside table before placing clean, dry washcloths on it. One CNA then used both gloved hands to provide front perineal care and repeatedly used the same contaminated gloved hands to obtain and wring out a washcloth from a basin of warm water, thereby contaminating the wash water each time. After completing the initial front incontinence care, the resident was assisted to the left side and verbalized that urination was occurring again. As the resident urinated, the CNA used the already contaminated incontinence brief to catch the urine and did not provide additional front perineal care afterward. The CNA then used the same contaminated gloves to remove the urine-saturated brief and place a new brief without removing gloves, performing hand hygiene, or donning clean gloves. Barrier cream was not applied at the end of incontinence care. The CNA later acknowledged that incontinence care should have been repeated after the resident urinated again and that gloves and wash water had been contaminated during the process.
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