Failure to Implement Infection Control Policies During Catheter and Incontinence Care
Penalty
Summary
Nurse Aide (NA) #3 failed to follow the facility's infection control policies while providing care to a resident who required enhanced barrier precautions (EBP) due to the presence of a urinary catheter. During the observed care, NA #3 did not don a gown as required by the EBP policy when performing urinary catheter care, despite signage and supplies being available at the resident's door. The resident was on EBP, which mandates gown and glove use during high-contact activities such as device care, but NA #3 was unaware of this requirement. Additionally, NA #3 did not adhere to the facility's hand hygiene policy during incontinence care. After cleaning stool from the resident, NA #3 failed to remove soiled gloves and perform hand hygiene before applying a clean brief and touching other items in the resident's environment. Interviews with the NA, Assistant Director of Nursing (ADON), Director of Nursing (DON), and Administrator confirmed that the expected procedures were not followed, as staff are required to remove gloves and perform hand hygiene after contact with stool and before touching other surfaces or items.