Failure to Follow Infection Prevention Protocols for Residents with Indwelling Urinary Devices
Penalty
Summary
The facility failed to follow infection prevention protocols for two residents with indwelling urinary devices. For one resident with a urostomy and colostomy, staff did not consistently use Enhanced Barrier Precautions as required. During care, a CNA donned appropriate personal protective equipment (PPE) when emptying the colostomy bag but failed to wear an isolation gown when emptying the urostomy bag, despite facility expectations and staff interviews confirming that a gown, gloves, and face shield should be used. Additionally, the resident's care plan lacked specific direction regarding Enhanced Barrier Precautions during device care, and the facility's catheter care policy did not address the need for such precautions for residents with indwelling urinary devices. For another resident with a suprapubic catheter, a nurse cleansed the catheter insertion site while wearing gloves but did not change gloves before applying a new dry dressing, contrary to facility expectations and staff interviews. The nurse acknowledged forgetting to change gloves during the observed care. The facility's policy on suprapubic catheter care did not include steps for applying a clean dry dressing, contributing to the lack of adherence to infection control protocols.