Failure to Follow Infection Control Protocols for PPE Use and Catheter Bag Labeling
Penalty
Summary
Facility staff failed to observe proper infection control measures for two residents. In the case of one resident on enhanced barrier precautions (EBP), a Certified Nurse Assistant (CNA) was observed providing activities of daily living (ADL) care without donning the required personal protective equipment (PPE), specifically a gown, despite signage indicating the need for PPE before entering the room. The CNA stated unawareness of the requirement to continuously wear PPE while providing care to a resident on EBP, and only removed PPE after care was completed. Interviews with the infection prevention nurse and Director of Nursing confirmed that staff are expected to don PPE during physical contact with residents on EBP to prevent the spread of infection. For another resident with an indwelling catheter due to neurogenic bladder and a history of urinary tract infections, the facility failed to ensure the catheter bag was labeled with the date and time of the last change. During observation and interview, a Licensed Vocational Nurse (LVN) confirmed the absence of a label and stated that labeling is necessary to track when the bag was last changed, which is important for monitoring potential complications such as obstruction or infection. The resident's care plan included monitoring for infection and practicing good infection control, but the treatment administration record did not indicate when the catheter bag was last changed. Facility policy and procedures for both PPE use and urinary catheter care were reviewed. The PPE policy outlined the purpose and objectives for gown use, including preventing the spread of infections and exposure to bodily fluids. The urinary catheter care policy indicated that indwelling catheters or drainage bags are not to be changed on routine, fixed intervals, but did not address labeling requirements. These observations and interviews demonstrate lapses in adherence to established infection prevention and control protocols.