Failure to Change Gloves During Catheter Care
Penalty
Summary
A deficiency was identified when staff failed to follow proper infection control procedures during catheter care for a resident with a history of benign prostatic hyperplasia, recurrent urinary tract infections, and severe cognitive impairment. The resident's care plan required catheter care twice daily and as needed, including cleansing the urinary meatus, and specified the use of Enhanced Barrier Precautions. During an observed episode of catheter care, a certified nurse aide provided care to the resident but did not change gloves after performing catheter care. The aide continued to touch the resident, medical equipment, furniture, and retrieved a new incontinent brief, all while wearing the same soiled gloves. The aide then assisted with transferring the resident and continued to touch various surfaces and the resident before finally removing and discarding the gloves. The aide later confirmed that gloves had not been changed after providing catheter care, acknowledging this was not in line with expected practice. The facility was unable to provide a policy regarding glove changes during catheter care when requested by surveyors.