Failure to Follow Infection Control and Catheter Care Protocols
Penalty
Summary
Staff failed to follow proper infection control and catheter care procedures for a resident with an indwelling urinary catheter. During observed catheter and perineal care, a CNA used the same side of a washcloth multiple times to clean different areas, did not rinse or dry the resident’s skin after cleaning, and did not perform hand hygiene between glove changes. The CNA also did not consistently use the required Enhanced Barrier Precautions (EBP), such as wearing a gown, during high-contact care activities. Interviews with staff confirmed a lack of adherence to hand hygiene protocols and proper use of personal protective equipment as outlined in facility policy. The resident involved had a history of multiple sclerosis, neurogenic bladder, and a recent urinary tract infection, and was dependent on staff for toileting. The care plan specified the need for EBP due to the presence of an indwelling catheter and a history of multidrug-resistant organism colonization. Despite these documented needs, staff did not consistently implement the required precautions or follow the facility’s catheter care policy, which included specific steps for cleaning, drying, and securing the catheter and surrounding area. Additionally, the resident reported being without an anchoring strap for the catheter tubing, resulting in the tubing being taped to the thigh, which caused irritation and pulling. Observations revealed the catheter bag was leaking and covered with a stained pillowcase, and the bag was not promptly changed after the leak was reported. Staff interviews confirmed that the expected practice was to use proper anchoring devices and to change leaking catheter bags immediately, but these actions were not taken in a timely manner.