Failure to Follow Infection Control Protocols During Incontinence and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinence and catheter care for two residents. In the case of one resident with severe cognitive impairment and total dependence for personal hygiene, both an LVN and a CNA performed peri care without changing gloves or performing hand hygiene between dirty and clean tasks. The staff also failed to sanitize their hands after glove removal, and one staff member left the resident's room without performing hand hygiene. Both staff acknowledged during interviews that they did not follow proper procedures, including not bringing hand sanitizer into the room. For another resident with intact cognition and a Foley catheter, a CNA provided catheter and incontinence care without donning the required gown for Enhanced Barrier Precautions (EBP), despite signage and supplies being available outside the room. The CNA changed gloves multiple times without performing hand hygiene and placed used linens and trash bags on the floor, contrary to infection control protocols. The CNA admitted to forgetting to wear the required PPE and recognized the importance of hand hygiene and proper disposal of contaminated materials. Record reviews confirmed that both residents required assistance with personal hygiene and were at risk for infection due to their medical conditions. Facility policies required hand hygiene after glove removal and the use of appropriate PPE for residents on EBP, especially those with indwelling medical devices. Staff interviews further confirmed awareness of the correct procedures, but these were not followed during the observed care activities.