Failure to Prevent Cross Contamination During Catheter Care
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow proper infection control procedures during catheter care for a resident with multiple complex medical conditions, including hereditary spastic paraplegia, morbid obesity, neuromuscular dysfunction of the bladder, and a suprapubic catheter. The LPN removed a contaminated split gauze from the resident’s suprapubic catheter insertion site, which had yellow/pink drainage, and cleansed the area by wiping the gauze back and forth multiple times over the same area. Without changing gloves or performing hand hygiene, the LPN then placed a new split gauze over the insertion site using the same contaminated gloves. The resident’s medical records indicated a physician’s order for twice-daily cleansing of the suprapubic catheter site, but the resident reported that staff never clean the site daily, only during monthly catheter changes. The LPN acknowledged contaminating the site by not changing gloves between cleaning and dressing application. The Director of Nursing confirmed that contaminating an open wound could lead to infection. Facility policy required staff to discard gloves and perform hand hygiene after cleansing around the catheter site, which was not followed in this instance.