Failure to Follow Infection Control Standards During Catheter Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide urinary catheter care according to current infection control standards for a resident with severe cognitive impairment and multiple diagnoses, including neurocognitive disorder with Lewy bodies, Parkinson's disease with dyskinesia, and flaccid neuropathic bladder. The resident was dependent on staff for personal hygiene and had an order for catheter care every shift. During observed catheter care, the CNA placed wipes directly on the fitted sheet, used wipes to clean the resident's perineal area and catheter tubing, and repeatedly failed to perform hand hygiene or change gloves at appropriate times, such as after handling the trash can, after providing catheter care, and before emptying the catheter drainage bag. The CNA also used gloved hands to touch multiple surfaces, including the bathroom door, nightstand, and supply items, without changing gloves or performing hand hygiene between tasks. Additionally, the CNA returned a package of wipes from the resident's room to the supply cart in the hallway without performing hand hygiene, and the Director of Nursing (DON) confirmed that this was typical practice. The facility's policy required standard precautions, clean technique, and hand hygiene before and after glove use and handling of catheter supplies, but these procedures were not followed during the observed care. The DON stated that hand hygiene and glove changes were expected at several points during catheter care, but these expectations were not met during the observed incident.