Infection Control Failures in Wound Care and Catheter Management
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices involving wound care and indwelling urinary catheter management for four residents. During a wound dressing change for a resident with a severe cognitive impairment and a history of stroke, hypertension, and neurogenic bladder, an LPN donned gloves and then touched potentially contaminated items, such as her pocket and treatment cart keys, before handling wound care supplies. The LPN did not change gloves after these contacts, failed to rinse the wound thoroughly after applying Hibiclens as ordered, and touched sterile gauze pads with contaminated gloves. The facility's hand hygiene policy required handwashing or use of alcohol-based hand rub after contact with objects in the resident's vicinity, which was not followed. For three other residents with indwelling urinary catheters, surveyors observed that the catheter drainage bags were either dragging on the floor or resting directly on the bare floor in multiple locations and at different times. One resident's catheter bag was seen dragging on the floor while she was in the dining room and being transported through hallways. Another resident's catheter bag was observed with two to three inches in direct contact with the floor while he was in bed, and a third resident's catheter bag was repeatedly seen with about one inch resting on the floor while she sat in her recliner. Staff interviews confirmed that catheter bags should not be in contact with the floor, and the facility's policy required appropriate care in accordance with professional standards. The clinical records for the affected residents indicated significant medical histories, including diabetes, acute neurological disorders, stroke, benign prostatic hyperplasia, and neurogenic bladder. Observations and interviews confirmed that staff did not adhere to established infection control protocols for both wound care and catheter management, as required by facility policy and professional standards.