Failure to Provide Hand Hygiene and Proper Catheter Bag Management
Penalty
Summary
The facility failed to implement effective infection prevention and control practices as evidenced by the lack of hand hygiene offered to residents prior to meals and improper management of a urinary catheter drainage bag. During multiple dining observations, staff did not offer hand hygiene to residents before meals, despite the facility's policy requiring assistance with hand hygiene before eating. Staff interviews confirmed that hand hygiene was not routinely provided, and both residents and visitors reported not being offered hand hygiene before meals. The Infection Control nurse acknowledged the lapse and noted that individualized hand wipes were not provided as intended. Additionally, a resident with a urinary catheter was observed on several occasions with the catheter drainage bag dragging on the floor and scraping against the wheelchair wheel. Staff, including the Infection Preventionist, did not intervene to correct the situation. The facility's policy on catheter-associated urinary tract infections specifies that catheter drainage bags should not be placed on the floor, a guideline that was not followed in this instance. The Director of Nursing and Regional Nurse Consultant confirmed that proper catheter bag management was not maintained.