Failure to Follow Infection Control Practices During Perineal and Catheter Care
Penalty
Summary
Staff failed to adhere to infection control practices and facility policies during perineal care and suprapubic catheter care for one resident with a suprapubic catheter. Observations revealed that Certified Nurse Aides (CNAs) performed peri care and catheter care while wearing the same soiled gloves, then proceeded to touch the resident's clothing, mechanical lift, bed rails, linens, catheter bag, and tubing without changing gloves or performing hand hygiene. After completing these tasks, one CNA removed gloves and performed hand hygiene, while the other handled trash before performing hand hygiene. Both CNAs acknowledged during interviews that they should not have touched items with soiled gloves and recognized this as a breach of infection control protocol. Further observation showed that perineal care was performed using improper technique, including not washing the head of the penis or pulling back the foreskin, not using a clean area of the washcloth for each stroke, and failing to dry the area. The same soiled gloves were used to touch various surfaces and items in the resident's room, including the privacy curtain, nightstand, covers, and incontinent protectors. The CNA admitted after the procedure that gloves should have been changed between tasks and acknowledged touching items with soiled gloves without realizing it at the time.