Failure to Follow Infection Control Protocols During Catheter and Wound Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices for two residents observed during survey. In one instance, a CNA provided catheter care to a resident on Enhanced Barrier Precautions (EBP) without donning a gown, despite clear signage and care plan instructions requiring gown use for close contact care. The resident had an indwelling Foley catheter and diagnoses including obstructive and reflux uropathy, urinary retention, and diabetes with chronic kidney disease. The CNA acknowledged that gowns were required for EBP, and the Infection Preventionist confirmed the omission. In a separate incident, a wound nurse performed wound care on another resident and failed to follow clean-to-dirty technique. The nurse used the same piece of gauze to clean both the inside and outside of a sacral wound multiple times, contrary to best practice standards and facility expectations. The nurse admitted this was not typical practice and should have used a new piece of gauze. Clinical support staff confirmed that staff should not move from clean to dirty areas with the same gauze, and the facility lacked a specific policy on clean-to-dirty technique.