Failure to Follow Infection Control Practices for Residents with Medical Devices
Penalty
Summary
Staff failed to follow infection control practices for a resident with a feeding tube and another with a catheter. For the resident with a feeding tube, a registered nurse donned gloves and gown for Enhanced Barrier Precautions (EBP) but did not perform hand hygiene or remove gloves between tasks such as obtaining vital signs, administering insulin, handling medication packaging, and documenting care. Equipment used for blood sugar, blood pressure, and pulse oximetry was placed back into the medication cart without being sanitized. The nurse continued to access the medication cart and administer medications via gastrostomy tube without changing gloves or performing hand hygiene, only removing gloves and gown at the end of the process. Additionally, certified nursing assistants providing hygiene and transfer for the same resident donned gowns and gloves but failed to perform hand hygiene between glove changes and did not consistently don new gowns as required by EBP protocols. For the resident with an indwelling catheter, observations on three separate occasions revealed that the catheter bag was lying on the floor with the drain port touching the floor. The Director of Nursing confirmed during an interview that the catheter bag should not be on the floor. These findings were based on direct observation, staff interviews, and policy review, and indicate lapses in adherence to established infection prevention and control procedures for residents with medical devices.