Failure to Maintain Infection Control During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nurse aide (CNA) failed to follow proper infection control practices during catheter care for a resident with a suprapubic catheter. The resident, who had intact cognition and diagnoses including paraplegia and neurogenic bladder, required daily catheter site care as documented in the care plan and treatment administration record. During the observed procedure, the CNA entered the resident's room, donned an isolation gown, and put on gloves without performing hand hygiene. The CNA proceeded to handle the resident's catheter and supplies without changing gloves or performing hand hygiene at appropriate intervals, as required by facility policy. The CNA removed and replaced the gauze dressing on the suprapubic catheter tubing, but when a new package of gauze was dropped on the floor, the CNA initially attempted to use it rather than discard it, only disposing of it after repeated instruction from the Assistant Director of Nursing (ADON). Throughout the procedure, the CNA continued to touch various surfaces and supplies, including opening drawers and cabinets, and handling a graduated cylinder for urine measurement, all while wearing the same pair of gloves. Hand hygiene was not performed between clean and dirty tasks, nor after glove removal until the end of the procedure. Facility policy and the catheter care audit tool both require hand hygiene before and after glove use, and after contact with potentially contaminated items. The observed actions did not align with these protocols, as the CNA failed to perform hand hygiene at critical points and did not change gloves when indicated, leading to a breach in infection prevention and control practices for the resident with an indwelling catheter.