Infection Control Failures in Resident Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. In the first instance, a certified nursing assistant (CNA) was observed providing peri and Foley catheter care to a resident with a history of cerebral infarction and neuromuscular bladder dysfunction, who was on Enhanced Barrier Precautions due to a Foley catheter and ulcers. During care, the CNA removed a bed wedge from the resident's bed, which then fell to the floor. The CNA subsequently picked up the wedge from the floor and placed it back onto the resident's bed without cleaning or sanitizing it, despite the resident's increased risk for infection. In the second instance, a registered nurse (RN) provided PEG tube site care to a resident with dementia, cerebral infarction, and dysphagia requiring tube feeding. The RN removed the resident's old gauze bandage from the PEG tube site and, without changing gloves or performing hand hygiene, applied a new bandage. The RN acknowledged that he should have changed gloves and sanitized his hands between removing the old bandage and applying the new one, as per infection control protocols. Both staff members involved were aware of the correct procedures and acknowledged during interviews that their actions did not align with facility policy or infection control standards. Facility policies reviewed confirmed the requirement for cleaning reusable equipment after contamination and for performing hand hygiene before and after glove use, especially during wound care and when handling potentially contaminated items.