Infection Control Deficiencies in Catheter and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances, leading to deficiencies in care. One resident with an indwelling urinary catheter had their catheter collection bag lying on the floor, which was confirmed by a registered nurse. This is contrary to the facility's policy, which states that catheter tubing and drainage bags should be kept off the floor to prevent catheter-associated complications, including urinary tract infections. Another deficiency was observed during a dressing change for a resident with a wound. The facility's policy requires the establishment of a clean field and the cleaning of the bedside stand before and after the procedure. However, during the dressing change, the licensed practical nurse and nurse aide did not clean the bedside stand, leading to potential cross-contamination. Additionally, there was no signage or orders indicating the need for enhanced barrier precautions, which are necessary for residents with wounds to prevent the spread of multi-drug resistant organisms. The infection preventionist confirmed that enhanced precautions were not ordered for the resident, and the staff involved were unaware of the need for such precautions. This lack of awareness and failure to follow established protocols contributed to the facility's inability to prevent cross-contamination and maintain proper infection control practices.
Plan Of Correction
Resident R53's urinary draining bag was changed and secured properly at the time of survey. Resident R54 was placed in Enhanced Barrier Precautions at the time of survey. Resident R54's wound has since been examined and has had no negative impact from the lack of EBP during the dressing change. The bedside table was sanitized after being notified by the surveyor. A whole house sweep was conducted at the time of survey to ensure all urinary drainage bags were being properly secured for infection control purposes. A whole house audit was completed at the time of survey to ensure all residents meeting the criteria for EBP were ordered with proper signage present. The DON or designee will educate all licensed staff on sanitizing the bedside table after dressing changes and indications for implementing EBP for residents. All nursing staff will be educated in infection control as it relates to urinary drainage bags. The DON or designee will audit one dressing change daily x 3 days, then one dressing change weekly x 8 weeks. All results to be reviewed through QAPI for further recommendation. 2/25/25 R53's urinary drainage bag was changed and secured properly at the time of survey. Resident R54 was placed in Enhanced Barrier Precautions immediately at the time of survey. Resident R54's wound has since been examined and has not had any negative impact from the lack of EBP during the dressing change. The bedside table was sanitized immediately after being notified by the surveyor. A whole house sweep was conducted at the time of survey to ensure all urinary drainage bags were being properly secured for infection control purposes. A whole house audit was completed at the time of survey to ensure all residents meeting criteria for EBP were ordered isolation precautions and had proper signage in place. The DON or designee will educate all licensed staff on sanitizing the bedside table after dressing changes and indications for implementing EBP for residents. All nursing staff will be reeducated on Infection Control and how it relates to urinary drainage bags. The DON or designee will audit one dressing change daily x 3 days, then one dressing change weekly x 8 weeks. All results to be reviewed through QAPI for further recommendation. The infection preventionist will continue to perform ongoing twice weekly audits to ensure all residents on Enhanced Barrier Precautions have appropriate orders/signage/supplies in place/present for use. All results will be reviewed through QAPI for further recommendations.