Failure to Follow Infection Control Protocols During Central Line Dressing Change
Penalty
Summary
A deficiency occurred when a nurse failed to follow established infection prevention and control protocols during a central venous catheter (CVC) dressing change for a resident with end stage renal disease requiring hemodialysis. The nurse entered the resident's room without donning a gown or mask, placed a prepackaged dressing on a surface without using a barrier, and after hand hygiene and gloving, applied an adhesive dressing over the resident's dialysis access site without first cleansing the site. The nurse also did not provide a mask for the resident, as required by facility policy and the contents of the central line dressing kit. Facility policies and recent CMS guidance require the use of enhanced barrier precautions (EBP), including gown and glove use, and the cleansing of the catheter insertion site with an approved antiseptic solution prior to dressing application. The nurse did not follow these protocols, and the Director of Nursing confirmed that the expected procedures were not adhered to, including the use of appropriate PPE, site cleansing, and supply barriers. The resident's care plan and physician orders specified regular and as-needed dressing changes for infection prevention, but the observed dressing change did not meet these standards.