Failure to Follow Infection Control Protocols During Incontinence and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by improper infection control practices during and after incontinence care for one resident with an indwelling catheter. During observation, an LPN performed incontinence and catheter care without adhering to hand hygiene protocols, including not changing gloves or performing hand hygiene between contaminated and clean tasks. The LPN used soiled gloves to handle clean linens, touched the resident's clean areas, and exited the resident's room without sanitizing hands. Additionally, soiled washcloths were placed on the floor instead of in the designated dirty linen basin, and the LPN failed to wipe away from the catheter tubing and vaginal area as required by facility policy. Interviews with the LPN and the Director of Nursing confirmed that the observed practices did not align with facility policies for catheter care, hand hygiene, and handling of soiled linens. The LPN acknowledged not changing gloves or performing hand hygiene at appropriate times, placing soiled linens on the floor, and not following proper wiping technique. The Director of Nursing confirmed that staff are expected to change gloves when moving from contaminated to clean areas, sanitize hands between glove changes, and properly dispose of soiled linens.