Failure to Follow Infection Control Protocols for Indwelling Devices and Wound Care
Penalty
Summary
Staff failed to follow infection prevention and control protocols for two residents with complex medical needs. For one resident with a Foley catheter, PICC line, and feeding tube, the Foley catheter drainage bag was observed sitting directly on the floor without a privacy bag, and the emptying spout was in contact with the floor. Additionally, during care procedures involving the PICC line and feeding tube, an LPN did not perform hand hygiene before donning gloves, between glove changes, or after removing gloves, despite handling invasive devices and administering medications. For another resident with multiple pressure injuries and orders for Enhanced Barrier Precautions (EBP), wound care was performed by two staff members who donned gloves but failed to wear gowns as required by EBP protocols. The signage for EBP was present in the room, and the care plan and physician orders specified the use of EBP, but staff did not comply with the gown requirement during wound care. Interviews with staff and the Director of Nursing confirmed awareness of the required infection control practices, including hand hygiene and the use of gowns and gloves for residents on EBP. However, the observed failures to implement these practices during direct care led to deficiencies in the facility's infection prevention and control program.