Failure to Maintain Infection Control Procedures for Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies related to both staff and resident practices. One deficiency involved a resident with an indwelling urinary catheter who independently managed her catheter care. The resident was observed emptying her catheter bag without performing hand hygiene before or after the procedure, touching both the toilet seat and the catheter bag with bare hands, and leaving the catheter bag on the floor without a privacy cover. The resident reported not recalling any education on proper catheter care, and her care plan did not address her self-management of the catheter or include steps for staff to ensure proper infection control practices. There was also no documentation of assessment, education, or monitoring to ensure the resident adhered to infection control guidelines. Another deficiency was identified in the staff's failure to follow Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Multiple staff members, including CNAs, were observed providing high-contact care activities such as incontinence care and transfers to residents on EBP without donning the required gowns, although gloves were used. Staff interviews revealed inconsistent awareness and adherence to EBP protocols, with some staff citing reasons such as not noticing signage or being in a hurry. The facility's policy and CDC guidelines require both gown and glove use for high-contact care activities for residents on EBP, but these were not consistently followed. The report documents that the facility's infection control failures occurred across more than one unit and involved both direct care staff and the lack of appropriate care planning and assessment for residents managing their own medical devices. The observations and interviews confirm that the facility did not ensure adherence to established infection control procedures, as required by both facility policy and professional guidelines.