Failure to Implement Effective Infection Prevention and Control Practices
Penalty
Summary
The facility failed to implement an effective infection prevention and control program for three residents, resulting in multiple deficiencies related to the handling of urinary catheters and oral suction equipment. For one resident with an indwelling urinary catheter, the drainage bag and tubing were repeatedly disconnected and reconnected between a bedside drainage bag and a leg bag. The tubing tip was left uncapped and exposed to air or tucked inside a dignity bag, and the same drainage bag was reused daily for up to a month. Staff interviews confirmed awareness of this practice, which was inconsistent with facility policy requiring a new drainage bag and tubing whenever the closed system is compromised. Another resident, who was dependent on staff for all care and required frequent oral suctioning, had a suction cannister at the bedside that was not changed daily. The cannister, containing oral secretions, was observed to have been in use for over a week, with staff confirming that the cannister and tubing should be disposed of daily. The facility did not have a policy specifying the required frequency for changing suction equipment, but staff and the infection preventionist stated that best practice was to change it every 24 hours to prevent bacterial growth. A third resident with a chronic indwelling urinary catheter was observed multiple times with the catheter bag and tubing touching the floor. The infection preventionist confirmed that the bag and tubing should be kept off the floor to prevent contamination, and the facility's policy also required this. Despite these requirements, the issue persisted over several observations, and staff acknowledged responsibility for ensuring the catheter bag was properly positioned.