Failure to Follow Infection Control Practices for Catheter Care, Equipment Disinfection, and PPE Use
Penalty
Summary
Staff failed to follow proper infection control practices in several instances involving residents with complex medical needs. One resident with a urinary catheter and a history of spina bifida, paraplegia, and recurrent urinary tract infections was observed multiple times with their catheter drainage bag placed directly on the floor without a barrier, contrary to facility policy and staff instructions. The resident expressed a preference for the bag to be as low as possible, sometimes resulting in the bag being placed on the floor. Staff interviews confirmed awareness that placing the catheter bag on the floor was an infection control issue, but the practice continued due to the resident's preferences and concerns about drainage effectiveness. In another instance, staff failed to clean and disinfect a mechanical transfer lift between uses for different residents. Nursing assistants used the same lift for two residents without wiping it down or sanitizing it before or after each use. Staff interviews confirmed knowledge of the requirement to clean equipment between residents to prevent infection transmission, but this protocol was not followed during the observed instances. Additionally, proper use of personal protective equipment (PPE) was not maintained by housekeeping staff when cleaning rooms under contact precautions. A housekeeper was observed wearing the same gown while cleaning multiple rooms, only changing gloves between rooms, despite facility policy and supervisor expectations that both gown and gloves should be changed after each room. Interviews with the housekeeper and supervisors confirmed that the correct procedure was not followed, increasing the risk of cross-contamination between rooms.