Failure to Follow Infection Control Protocols During Catheter Care and Glucometer Use
Penalty
Summary
Staff failed to follow infection prevention and control protocols during two observed care activities. During catheter care for a resident with multiple sclerosis and neuromuscular dysfunction of the bladder, both a CNA and a Lead CNA did not wear gowns as required by Enhanced Barrier Precautions (EBP), despite signage and facility policy indicating the need for both gloves and gowns. The Lead CNA's clothing came into contact with the resident's bed, further breaching protocol. Both staff members acknowledged their failure to use gowns, and interviews with the Infection Preventionist and Director of Nursing confirmed that EBP, including gown use, was expected for residents with urinary catheters. Additionally, during medication administration, an LPN did not properly clean and disinfect a multi-use glucometer according to the manufacturer's instructions. The LPN wiped the glucometer for only a few seconds before allowing it to dry for two minutes, rather than ensuring the required contact time with the germicidal wipe. The DON confirmed that staff misunderstood the cleaning directions, and both acknowledged that not following the manufacturer's guidelines could result in the spread of infection.