Failure to Implement Infection Control Precautions and Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program for two residents. For one resident with a central venous catheter port, staff did not implement Enhanced Barrier Precautions (EBP) as required. The resident, who had a port placed for chemotherapy, reported that nurses had not changed his dressing and staff did not use gowns or gloves during care. There was no EBP signage or PPE cart outside the resident's room, and both nursing and CNA staff confirmed that EBP should have been in place for residents with indwelling devices or wounds. The Director of Nursing also acknowledged that EBP should have been implemented upon admission for such residents. Another resident with an indwelling urinary catheter was observed to have dark, foul-smelling urine with visible mucus and sediment in the catheter tubing. The room had a strong odor of urine. Staff interviews confirmed that these were signs of a possible urinary tract infection and that such findings should be reported to a nurse. The resident's physician order required the catheter drainage bag to be changed monthly and as needed, but this order was not entered as a task in the Treatment Administration Record, and the change was not completed as ordered. Nursing staff confirmed that the catheter tubing should have been changed and that the physician should have been notified of the abnormal findings. Record reviews and staff interviews further revealed that the facility's infection preventionist and Director of Nursing expected staff to be competent in catheter care and to escalate any concerns, such as signs of infection, to the physician. The care plan for the resident with the urinary catheter also required staff to report signs and symptoms of infection and to change the catheter as ordered. However, these expectations were not met, resulting in a failure to follow infection control protocols and physician orders for both residents.