Failure to Follow Infection Control Protocols During Device Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during care for two residents with indwelling medical devices. In one instance, an LPN administered medication via a percutaneous endoscopic gastrostomy (PEG) tube without donning a gown, as required by the facility's Enhanced Barrier Precautions (EBP) policy and CDC recommendations. The LPN acknowledged she was trained on EBP and recognized the omission, and both the Infection Preventionist and Director of Nursing confirmed that a gown should have been worn to prevent potential transmission of infection. In another instance, an LPN provided suprapubic catheter care to a resident but did not follow the facility's policy for cleaning the catheter site. The LPN used the same section of a washcloth in a circular motion multiple times before flipping to a clean section, rather than using a clean section for each wipe as required. The LPN, Infection Preventionist, and Director of Nursing all confirmed that this technique could transfer bacteria and increase the risk of infection. Both residents involved had relevant medical conditions requiring these devices and care procedures.