Failure to Follow Infection Control Protocols for Wound Care and Catheter Management
Penalty
Summary
Surveyors identified deficiencies in infection control practices related to enhanced barrier precautions (EBP) and urinary catheter care. For one resident with a diabetic foot ulcer and chronic kidney disease, a LPN performed wound care without donning a gown, despite a posted EBP sign and the availability of gloves and gowns in the room. Facility policy required the use of gloves and gowns for high-contact care activities such as wound care, but this protocol was not followed during the observed event. The LPN confirmed not wearing a gown prior to entering the resident's room. Additionally, another resident with an indwelling urinary catheter was observed multiple times with the urinary drainage bag lying flat on the floor, with the drainage spout touching the floor. Facility staff confirmed that the urinary drainage bag should not be on the floor, as per infection control standards. Both incidents were confirmed through staff interviews and direct observation, indicating a failure to adhere to established infection prevention and control policies.
Plan Of Correction
Director of Nursing or designee will provide education to all nursing staff on Infection Control and Enhanced Barrier Precautions. Education will include catheter care and placement. All education will be completed by 08/30/2025. Identified resident's, R4, catheter bag was removed from the floor immediately and staff working the hall were educated. All residents with a catheter were checked to ensure that their catheter bag was properly placed. Nurse that provided wound care was immediately educated. Resident R9 was monitored for signs and symptoms of infection for five days. Ongoing compliance will be monitored by Director of Nursing or designee by observing nursing staff following enhanced barrier requirements on 10% of residents with orders for enhanced barrier precautions one time per day 3x week for 2 weeks, one time per day weekly for 2 weeks and one time per day monthly for 2 months. Audits shall cover all shifts and all residents with orders for enhanced barrier precautions. Director of Nursing or designee will do an audit all residents with catheters will be checked to ensure the catheter bags are not placed on the floor one time per day 3x week for 2 weeks, one time per day weekly for 2 weeks and then one time per day monthly for 2 months. Audits shall cover all shifts and all residents with orders for a catheter. Findings will be reviewed in monthly Quality Assurance and Performance Improvement meetings.