Infection Control Lapses in IV Tubing, PPE Use, and Catheter Care
Penalty
Summary
The facility failed to follow infection prevention and control practices for two residents. For one resident with a peripherally inserted central catheter (PICC) line, the intravenous (IV) tubing was observed to be undated while medication was being administered. Physician orders required daily changes of the IV tubing, and facility policy specified that new tubing should be labeled with the date, time, and initials. The Director of Nursing (DON) confirmed the tubing was not dated as required by policy. In another instance, a Certified Nursing Assistant (CNA) was observed providing direct care to a resident, including changing briefs and emptying a Foley catheter bag, without wearing personal protective equipment (PPE) such as gloves and a gown. The resident had a physician order for Enhanced Barrier Precautions (EBP) due to the presence of an indwelling Foley catheter, and signage outside the room indicated that PPE was required for high-contact care activities. The CNA acknowledged not wearing PPE during these activities, and the Infection Prevention Nurse confirmed that PPE should have been used. Additionally, the same resident's Foley catheter drainage bag was observed on the floor and uncovered. Facility policy and the DON confirmed that catheter drainage bags should not be in contact with the floor to maintain infection control standards. The resident's clinical record indicated a diagnosis of urinary retention and an order for an indwelling Foley catheter.