Infection Control Lapses in Tracheostomy, Foley Catheter, and Contact Precaution Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices in several instances involving residents with specialized care needs. One resident with a tracheostomy was observed with their trach collar oxygen mask lying on the floor next to the bed on two separate occasions, with the mask dated several days prior. The mask was not replaced until after the issue was brought to the attention of the unit manager, who confirmed the mask had been on the floor and acknowledged the importance of infection prevention in this context. Another deficiency was observed with a resident who had a Foley catheter. A used Foley catheter with visible urine in the tubing and collection bag was found placed directly on the bedside table next to personal care items, rather than being immediately discarded in a biohazard receptacle as required by facility policy. The nurse responsible admitted to forgetting to dispose of the catheter and acknowledged that this action was against infection control policy, which was confirmed by both the Infection Preventionist and the Director of Nursing. Additional infection control lapses were identified with two residents on contact precautions. Staff were observed entering rooms with posted contact precaution signage without performing hand hygiene or donning required personal protective equipment (PPE), and in one case, a staff member handled items on the floor and exited the room without PPE or hand hygiene. Staff interviews revealed a lack of understanding or adherence to contact precaution protocols, and in some cases, staff were unaware of the reasons for the precautions. These failures were confirmed by supervisory staff and the infection prevention team during interviews.