Failure to Follow Hand Hygiene and Infection Control During Catheter and Perineal Care
Penalty
Summary
Staff failed to perform proper hand hygiene and infection control practices during catheter and perineal care for two residents. In one instance, two nurse aides provided catheter care to a resident with multiple diagnoses, including neuromuscular dysfunction of the bladder and multiple sclerosis, without performing hand hygiene before donning gowns and gloves. During the procedure, contaminated gloves were repeatedly used to remove cleansing wipes from the container, and hand hygiene was not performed after glove removal. The catheter drainage bag was also placed at or above the level of the bladder during a transfer, contrary to facility policy and physician orders. Both nurse aides confirmed in interviews that these actions were not in accordance with proper infection control procedures. In another case, two nurse aides performed catheter and perineal care for a resident with an indwelling catheter and multiple medical conditions, including fractures and chronic respiratory failure. Although hand hygiene was performed before donning gowns and gloves, one aide repeatedly reached into the wipes package with soiled gloves and failed to change gloves or perform hand hygiene between cleaning different body areas. The same soiled gloves were used to apply barrier cream to both the buttocks and the labia/groin folds without changing gloves or performing hand hygiene in between. The aide confirmed in an interview that these actions were not appropriate and did not follow infection control protocols. Facility policy reviews revealed that hand hygiene is required before and after handling invasive devices, after removing gloves, and after contact with blood or bodily fluids. Policies also specify that gloves do not replace hand hygiene and that the drainage bag should be kept below the level of the bladder. The Director of Nursing confirmed in interviews that the observed practices did not align with facility policies and expectations for infection prevention and control.