Failure to Prevent Cross-Contamination During Catheter and Incontinence Care
Penalty
Summary
Staff failed to provide appropriate catheter and incontinence care for multiple residents, resulting in cross-contamination and improper infection control practices. One resident with an indwelling urinary catheter for obstructive uropathy was observed with cloudy, sediment-laden urine and a soiled catheter insertion site. During catheter care, a CNA cleaned the resident's penis in the wrong direction, causing cross-contamination at the catheter insertion site, and failed to adequately clean the soiled catheter. The DON confirmed the improper technique and acknowledged the cross-contamination. Another resident, dependent on staff for all activities of daily living and with a diagnosis of neuromuscular dysfunction of the bladder, received perineal and catheter care from two CNAs. One CNA did not change gloves or perform hand hygiene after cleaning the front perineal area before moving to the rear, and a contaminated drainage bag cover was placed back over the urinary drainage bag after falling to the floor. Barrier cream was not applied after perineal care, contrary to facility policy. The DON confirmed that gloves should have been changed, hand hygiene performed, and a new drainage bag cover used. A third resident, severely cognitively impaired and dependent on staff, was provided incontinence care by two CNAs. After cleansing urine and feces from the resident's buttocks, a clean incontinence brief was applied without changing gloves or performing hand hygiene. The CNA later acknowledged the lapse, and the DON confirmed that hand hygiene should have been performed after incontinence care and before applying a new brief.