Failure to Follow Standard Precautions During Peri and Incontinence Care
Penalty
Summary
The deficiency involves failure to implement standard precautions during incontinence and peri care for one resident. The resident had intact cognition, multiple chronic conditions including chronic atrial fibrillation, osteoarthritis, anemia, essential hypertension, history of TIA, and sleep apnea, and was dependent on staff for transfers and toileting, with occasional bladder and bowel incontinence and a history of UTIs. During early morning care, a CNA provided peri care while the resident was side-lying, removed a urine-soaked brief and pad with strong urine odor, and began cleaning the buttocks with disposable wipes. After each use, the CNA threw the soiled wipes onto the floor. The CNA left the room to obtain a clean pad without removing gloves or performing hand hygiene, used the same contaminated gloves to open the door and access the clean linen cart, then returned and changed gloves without hand hygiene between glove changes. The CNA again left the room wearing gloves to obtain assistance, returned with another CNA, and continued care. Soiled wipes, the saturated brief, and the soiled bed pad were repeatedly thrown onto the floor, causing urine to splash onto the floor when the brief landed. After completing peri care and repositioning the resident, the CNA gathered the soiled items from the floor, bundled the used wipes and brief together, folded the soiled bed pad, and carried it under his arm with the contaminated surface touching his uniform. He then left the room still wearing the same gloves, disposed of the trash and linen, and handled the lids of the trash and soiled linen containers before finally removing his gloves and washing his hands at the end of the hall. Another CNA and the DON both confirmed that placing soiled items on the floor and wearing the same gloves from resident care into the hall and to the clean linen cart were not consistent with facility policy, which requires standard precautions including hand hygiene, proper PPE use, environmental care, linen handling, and waste disposal.
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