Failure to Implement Infection Control Practices During Perineal and Catheter Care
Penalty
Summary
Facility staff failed to implement infection prevention and control policies and procedures, resulting in unsanitary conditions and improper perineal and catheter care. During an observational tour, two clear plastic bags containing trash were found in the third-floor hallway next to a resident's room, contrary to facility protocol requiring immediate disposal in designated bins within the soiled utility room. Staff interviews confirmed that trash and soiled supplies should not be left in hallways, indicating a lapse in maintaining a sanitary environment. Additionally, a Certified Nursing Assistant (CNA) was observed performing perineal care for a resident with an indwelling urinary catheter and a history of recurrent UTIs. The CNA did not change gloves or perform hand hygiene when transitioning from contaminated to clean areas and did not change the water in the basin between cleaning steps, deviating from standard infection control practices. The resident was dependent on staff for all activities of daily living and had a care plan identifying elevated UTI risk due to the catheter. Staff interviews revealed inconsistent understanding of proper infection control protocols, and the Infection Control Preventionist acknowledged the concerns, confirming that staff are required to change gloves and wash hands between perineal and catheter care.