Failure to Disinfect Equipment and Use Proper PPE During Resident Transfers
Penalty
Summary
Staff failed to disinfect a mechanical lift between use with three different residents, as observed during transfers. The same lift was used consecutively for multiple residents without being sanitized in between, contrary to facility policy and staff statements that equipment should be disinfected after each use. Additionally, staff did not don appropriate personal protective equipment (PPE), specifically gowns, when transferring a resident on Enhanced Barrier Precautions (EBP) who had a suprapubic Foley catheter. Staff only wore gloves during the transfer and manipulated the resident's urinary catheter bag and tube feeding equipment without changing gloves or performing hand hygiene between tasks. During the transfer, the resident's catheter bag was positioned above the bladder, contrary to care plan instructions and facility policy, which require the bag to be kept below the bladder to prevent backflow. Staff interviews confirmed that gowns and gloves are required for such transfers and that failure to follow these protocols could be a source of infection. Facility policies reviewed also directed that reusable equipment be disinfected between residents and that standard precautions be used when handling urinary catheters.