Improper Infection Control Practices with Urinary Catheter
Penalty
Summary
The facility failed to adhere to proper infection control practices, as evidenced by the handling of a resident's indwelling urinary catheter. The resident, who was cognitively impaired and required assistance with care needs, had an indwelling urinary catheter due to a neurogenic bladder and had experienced a urinary tract infection in the past 30 days. During an observation, it was noted that the resident's catheter drainage bag and tubing were in direct contact with the floor, which is against the physician's orders that specified the catheter should be secured to the bed frame and not touch the floor. A nurse aide, upon being interviewed, confirmed the improper placement of the catheter bag and tubing. The aide then picked up the catheter bag and tubing with bare hands, without wearing gloves, and placed them back on the floor before donning gloves and placing the items into a dignity bag. The Director of Nursing confirmed that the nurse aide should have worn gloves when handling the catheter bag and tubing and should not have placed them on the floor while putting on gloves.
Plan Of Correction
Nurse Aide 1 received one on one education regarding catheter bag care, hand hygiene and use of personal protective equipment. Residents who have an indwelling Foley catheter have the potential to be affected. Nursing staff were educated by the Infection Control Nurse on hand hygiene, standard precautions, providing catheter care and the Chain of Infection. Monitoring will be captured through staff observations for hand hygiene. Observations will be conducted on 20 staff weekly for 2 weeks, then 10 staff weekly for 2 weeks, then 10 staff twice monthly for 2 months. The audits will be conducted by the Infection Control Nurse or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the Interdisciplinary team at QAPI Committee meeting.