Failure to Adhere to Hand Hygiene Protocols During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow appropriate infection prevention and control practices while providing catheter care to a resident with severe cognitive impairment and an indwelling catheter, who was also on Enhanced Barrier Precautions (EBP). During the observed care, the CNA performed hand hygiene and donned gloves and a gown, but did not perform hand hygiene between glove changes or after removing gloves at several points in the procedure. Specifically, after cleansing the catheter tubing and removing gloves, the CNA did not perform hand hygiene before donning new gloves. Additionally, after emptying the catheter bag and removing gloves, hand hygiene was again omitted before proceeding with the next steps. The Director of Nursing (DON) confirmed that the facility's expectation was for staff to perform hand hygiene between glove changes and when moving from one contaminated area to another, in accordance with the facility's infection control policy. The policy also required hand hygiene before and after resident contact, after contact with contaminated surfaces, before donning PPE, and after removing PPE. The observed failure to adhere to these procedures constituted a breach of the facility's infection prevention and control program.