Inadequate Hand Hygiene During Catheter Care
Penalty
Summary
The facility failed to ensure appropriate catheter care and hand hygiene for a resident, identified as R25, who was at risk for urinary tract infections. R25, who is cognitively intact and has a history of urinary retention and obstructive uropathy, was observed receiving catheter care from CNA H. During this process, CNA H did not change gloves or perform hand hygiene after completing catheter care and before handling the resident's gait belt and clothing. This action was contrary to the facility's hand hygiene policy, which requires hand washing or the use of alcohol-based hand rubs before and after direct contact with residents and after handling waste materials. The deficiency was further highlighted during an interview with CNA H, who acknowledged the failure to perform hand hygiene and glove changes as required. The Director of Nursing (DON B) also confirmed that hand hygiene and glove changes should have been performed between catheter care and assisting the resident with their clothing and mobility. This oversight in following proper infection control procedures could potentially contribute to the spread of infections, particularly given the resident's susceptibility due to their medical conditions.