Failure to Implement and Follow Infection Control Procedures for Residents with Indwelling Devices
Penalty
Summary
The facility failed to follow its own infection prevention and control policies and procedures, resulting in lapses in infection control for two residents. One resident with multiple wounds on the right foot, including a recent diagnosis of cellulitis and a dialysis catheter in the chest, was not placed on Enhanced Barrier Precautions (EBP) as required by facility policy. There were no EBP signs or infection control supplies at the entryway to the resident's room, and no order for EBP was present in the medical record at the time of observation and review. The infection control preventionist confirmed that residents with wounds and indwelling medical devices, such as central lines, should be on EBP, and the Director of Nursing agreed that EBP should have been implemented for this resident. Another resident with an indwelling urinary catheter and a history of urinary tract infections was observed with the catheter drainage bag lying flat and face down on the floor, rather than being properly hung on the bed. The Director of Nursing acknowledged that the drainage bag should not be on the floor, as this practice is inconsistent with infection control standards and increases the risk of contamination. Review of the facility's reference materials confirmed that catheter drainage bags should not be placed on the floor to prevent infection.