Failure to Follow Proper Catheter Care and Infection Control Procedures
Penalty
Summary
A certified nursing assistant (CNA) failed to provide catheter care in a manner that reduced the risk of contamination for a resident with an indwelling catheter. During the observed care, the CNA donned gloves but did not wear a gown as required for enhanced barrier precautions. After emptying the resident's catheter bag and removing gloves, the CNA did not perform hand hygiene before donning a new pair of gloves, which were taken from her pocket. Throughout the catheter care process, the CNA repeatedly used the same pair of gloves to touch various contaminated surfaces, including the resident's clothing, walker, soiled brief, trash can, and privacy curtain, before and during the cleaning of the resident's genitalia and catheter tubing. The CNA also handled clean supplies and applied a new brief with the same contaminated gloves, only removing them and performing hand hygiene at the end of the procedure. The resident involved had a history of malignant neoplasm of the prostate, benign prostatic hyperplasia with urinary tract symptoms, a history of urinary tract infections, and schizophrenia. Physician orders required regular catheter care and monitoring for signs and symptoms of urinary tract infection. Facility policy and signage indicated that both gown and gloves were required for all interactions with residents on enhanced barrier precautions, especially those with indwelling medical devices. The CNA was unsure about the need for hand hygiene after glove removal and acknowledged forgetting to don a gown, which was confirmed as a requirement by the facility's infection preventionist.