Failure to Follow Infection Control Practices During Catheter Care
Penalty
Summary
Staff failed to follow appropriate infection prevention and control practices while providing personal and catheter care to a resident on Enhanced Barrier Precautions (EBP). During the observed care, staff performed hand hygiene and donned gloves and gowns initially, but did not change gloves or perform hand hygiene after removing the lift cloth and before proceeding to cleanse the resident's meatus and catheter tubing. Additionally, after handling the catheter and emptying urine, staff did not consistently cleanse the catheter tip as required, and did not remove gloves and gowns or perform hand hygiene before leaving the resident's room. One staff member walked through common areas and hallways wearing contaminated gloves and gown, carrying used equipment, before removing personal protective equipment and performing hand hygiene in the utility room. The resident involved was nonverbal, had an indwelling catheter, and was always incontinent of bowel, as documented in the Minimum Data Set. Facility policy required hand hygiene before and after handling invasive devices, after removing gloves, and before leaving isolation precaution settings. The Director of Nursing confirmed that the observed practices did not meet facility expectations or policy requirements for infection prevention and control, particularly regarding hand hygiene, glove and gown removal, and proper cleansing of catheter equipment.