Failure to Adhere to Infection Control Protocols During Catheter and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple staff not adhering to established protocols during the provision of catheter and wound care for three residents. In one instance, a CNA performed catheter care for a resident with acute pyelonephritis and acute kidney failure but did not clean the resident's genitals, perineum, or meatus, contrary to facility policy and professional standards. The CNA believed that catheter care only involved cleaning the catheter itself and not the surrounding areas, which was confirmed during an interview. Another incident involved an LVN providing suprapubic catheter care to a resident with obstructive and reflux uropathy. The LVN did not don a gown as required under Enhanced Barrier Precautions (EBPs) and performed hand hygiene for less than the recommended 20 seconds on multiple occasions. The LVN acknowledged forgetting to wear a gown and was unsure about the duration of handwashing, despite being aware of the facility's expectations for hand hygiene and EBP compliance. A third deficiency was observed when an RN performed wound care for a resident with type 2 diabetes and hypertension. The RN washed her hands for only 9 seconds after completing the procedure, which did not meet the facility's or CDC's recommended hand hygiene duration. The RN admitted uncertainty about the exact time spent on handwashing but recognized the importance of proper hand hygiene. Interviews with facility leadership confirmed that staff were expected to follow specific protocols for hand hygiene and EBPs, but these were not consistently followed during the observed care activities.