Failure to Follow Infection Control Practices During Wound and Catheter Care
Penalty
Summary
The facility failed to implement proper infection control practices during wound care and catheter care for two residents. In the first instance, a resident with a history of arthritis, multiple sclerosis, malnutrition, and two Stage 2 pressure ulcers was observed receiving wound care from a registered nurse. The nurse cleansed the wound and, without changing gloves or performing hand hygiene, proceeded to apply zinc oxide and a new dressing, contrary to facility policy and standard infection control procedures. The facility's own wound care guidelines require staff to remove gloves and wash hands after cleansing a wound before applying new gloves for dressing application. In the second instance, a resident with heart failure, neurogenic bladder, diabetes, and an indwelling urinary catheter was observed with the catheter bag and tubing repeatedly resting on the floor, despite care plan interventions and posted Enhanced Barrier Precautions. Staff were seen handling the catheter bag and tubing without consistently using required personal protective equipment (PPE), such as gowns, and failed to clean the catheter spigot with an alcohol wipe after draining. The facility's policies and the resident's care plan specifically directed staff to keep catheter bags and tubing off the floor, use enhanced barrier precautions including gown and gloves, and clean the spigot after draining. Interviews with staff and the DON confirmed that the observed practices did not meet facility expectations or policy requirements. Staff acknowledged that gloves should be changed during wound care, catheter bags and tubing should never be on the floor, and appropriate PPE should be used during catheter care. The facility census at the time was 32 residents.