Failure to Ensure Nursing Staff Competency in Infection Control Procedures
Penalty
Summary
Registered Nurse (RN) 1 failed to correctly interpret and carry out a physician's order regarding the frequency of changing a resident's urinary catheter drainage bag. The order specified that the drainage bag should be changed every two weeks and as needed, but RN 1 initially believed the order was to change the bag only if needed every two weeks. This misunderstanding led to the drainage bag not being changed at the required intervals, contrary to the resident's care plan and physician's order. The Director of Nursing (DON) confirmed that the order was clear and that licensed nursing staff should have the competency to interpret and implement such orders. The Infection Preventionist Nurse (IPN) stated that not changing the drainage bag as ordered could harbor bacteria and lead to infection. In a separate incident, RN 2 and Licensed Vocational Nurse (LVN) 4 did not demonstrate knowledge of the facility's policy and procedure for replacing a resident's oxygen humidifier bottle. Observations revealed that a resident's humidifier bottle was not changed weekly as required by facility policy, and the date on the bottle had been altered rather than the bottle being replaced. LVN 4 admitted to not knowing the correct frequency for changing the humidifier bottle and stated she was following guidance from RN 2, who also did not follow the facility's policy. The DON and IPN confirmed that the policy required weekly changes for infection control purposes. Both incidents involved residents with significant cognitive impairments and dependence on staff for care. The failures by nursing staff to follow physician orders and facility policies placed residents at risk for infection and illness, as confirmed by the facility's infection preventionist and documented in the residents' care plans and medical records.