Failure to Follow Infection Control Protocols for Catheter Care and PPE Use
Penalty
Summary
Surveyors identified multiple deficiencies related to infection prevention and control practices. For one resident with a history of mechanical complication of a knee prosthesis, benign prostatic hyperplasia, and neuromuscular bladder dysfunction, observations revealed that the indwelling urinary catheter drainage bag was lying on the floor, contrary to physician orders and facility policy, which require the bag to be secured below the bladder and not in contact with the floor. Staff interviews confirmed awareness of the correct procedure, but the required practice was not followed. Another resident with Parkinson's disease, peripheral vascular disease, and dementia was on contact precautions due to an active infection with a highly transmissible pathogen (ESBL). Despite care plan interventions and facility policy requiring the use of personal protective equipment (PPE) upon room entry, the Administrator was observed entering the resident's room without donning any PPE. The Administrator confirmed this lapse during an interview. A third resident with diabetes, dementia, hypertension, atrial fibrillation, and obstructive uropathy had a suprapubic catheter and required enhanced barrier precautions. Observations showed the resident's catheter drainage bag was uncovered and on the floor, and staff transferring the resident did not wear the required gown and gloves during high-contact care activities, despite signage and policy indicating the need for PPE. Staff interviews confirmed knowledge of the requirements but acknowledged non-compliance during the observed care.