Failure to Maintain Infection Control During PICC Line Dressing Change and Incontinent Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the provision of care for two residents. In one instance, an LPN performed a peripherally inserted central catheter (PICC) line dressing change without adhering to sterile technique. The LPN placed the dressing kit on the resident's bed, used gloves from their pocket instead of sterile gloves for part of the procedure, and did not maintain sterility throughout the process. The LPN also left the room to retrieve a new dressing kit, removing and re-donning personal protective equipment, and continued the procedure without following sterile protocol. The resident involved had a history of orthopedic aftercare following surgical amputation and atherosclerosis with gangrene, and was ordered to have weekly PICC line dressing changes. In another instance, a CNA provided incontinent care to a resident without changing gloves between cleaning the peri area, applying cream, dressing the resident, and handling personal items such as the bed remote and hairbrush. The CNA also transported the resident's soiled clothing to the utility room without placing them in a bag, contrary to facility policy. The resident was dependent on staff for toileting and dressing and had a history of lower limb amputation. Both staff members acknowledged during interviews that their actions did not follow proper infection control procedures, and the DON confirmed the expected protocols for glove changes and handling of soiled linens.