Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
Nursing staff failed to implement appropriate infection control practices during indwelling urinary catheter (IUC) care for a resident with a suprapubic catheter. The resident, who had a history of stroke, neuromuscular dysfunction of the bladder, and obstructive reflux uropathy, required IUC care every shift. During an observed care episode, a nursing assistant used the same wipe to clean both the resident's perineal area and a small wound, then continued care without changing gloves or performing hand hygiene. The same soiled gloves were used to assist with turning the resident, changing the incontinence brief, and cleaning the front perineal area, before proceeding to IUC care without any glove change or hand hygiene. Interviews with staff confirmed that the correct procedure would have been to remove soiled gloves and perform hand hygiene between each area of care, and before starting IUC care. Both the infection preventionist and the director of nursing services acknowledged that the observed actions did not follow proper infection control protocols, which are necessary to prevent the spread of infectious pathogens during catheter care.