Infection Control Lapses in Catheter Care, Staff TB Testing, and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices in several areas. For one resident with an indwelling urinary catheter, observations revealed the catheter bag was left on the floor for an extended period, and the catheter insertion site and tubing had black dried debris, indicating inadequate catheter care. The assigned CNA was unable to confirm when catheter care was last provided and did not don personal protective equipment (PPE) as required for enhanced barrier precautions during care. Facility policy required the use of gown and gloves for residents on enhanced barrier precautions, but this was not followed. Additionally, signage and PPE supplies were present, but not utilized during care activities. Personnel file reviews showed that multiple staff members, including CNAs, LPNs, and the Activity Director, did not have timely pre-employment tuberculosis testing completed as required. During a medication administration observation, an LPN failed to perform hand hygiene before and after medication administration, wore the same gloves throughout multiple tasks, and did not remove gloves or clean hands before leaving the resident's room. The facility's hand hygiene policy required handwashing as the primary means to prevent infection, but this was not adhered to during the observed medication pass.