Infection Control Deficiencies: Catheter Bag Placement and Hand Hygiene Lapses
Penalty
Summary
Surveyors identified failures in infection control practices involving three residents. Two residents with urinary catheters were observed with their catheter dignity bags touching the floor, as documented by photo evidence. Both residents had significant medical histories, including urinary tract infections, sacral wounds, and dependence on external catheters. Their care plans required catheter bags to be positioned below the bladder and never touch the floor, with staff interviews confirming this expectation. However, observations showed that the dignity bags were not properly secured, resulting in direct contact with the floor. In another instance, a nurse performed tracheostomy care for a resident with chronic respiratory failure and severe cognitive impairment. During the procedure, the nurse failed to perform hand hygiene after removing gloves and before donning new gloves, contrary to facility policy and standard infection control protocols. The nurse stated that handwashing was not performed because no surfaces were touched after glove removal, but both the charge nurse and DON confirmed that hand hygiene is required after glove removal regardless of circumstances. Facility policies reviewed by surveyors clearly outlined the need for proper hand hygiene, including the '5 Moments of Hand Hygiene' and the requirement to perform hand hygiene before donning gloves and after glove removal. Staff interviews further confirmed awareness of these protocols, yet the observed practices did not align with policy, resulting in deficiencies in infection prevention and control measures for the sampled residents.