Deficient Infection Control Practices: PPE, Hand Hygiene, and Catheter Care
Penalty
Summary
The facility failed to ensure proper use of Personal Protective Equipment (PPE) and hand hygiene practices, as well as appropriate handling of an indwelling urinary catheter drainage bag, as observed during surveyor visits. One staff member, a Nursing Assistant Certified (NAC), was seen wearing a soiled N95 mask when exiting a Droplet Precautions room and did not change to a new mask before entering other resident rooms, despite a PPE cart being available outside the rooms. Interviews with staff revealed inconsistent understanding and application of the facility's policy regarding when and where to change masks after providing care to residents on Droplet Precautions. Hand hygiene deficiencies were also observed during meal tray delivery to three residents. A staff member delivered meal trays, adjusted bedside tables, and moved walkers for multiple residents without performing hand hygiene before entering or after leaving the rooms, or between tasks. The staff member later acknowledged that hand hygiene should have been performed at these times, and supervisory staff confirmed that this was the expected practice according to facility policy. Additionally, the facility failed to maintain proper care of an indwelling urinary catheter for a resident with urinary retention and benign prostatic hyperplasia. The resident's catheter drainage bag was observed hanging under the bed and touching the floor on multiple occasions. Staff interviews confirmed that the drainage bag should not have been in contact with the floor and that a barrier should have been used to prevent this. These failures were directly observed and confirmed by multiple staff members during interviews.