Failure to Follow Infection Control Practices During Catheter Care
Penalty
Summary
During routine suprapubic catheter care for a resident with a history of obstructive and reflux uropathy, major depressive disorder, insomnia, chronic pain syndrome, and prior cerebrovascular events, staff failed to follow proper infection control practices. The resident, who was cognitively intact and dependent on staff for toileting, had physician orders and care plan interventions specifying catheter site cleansing every shift with soap and water, use of split gauze, and documentation of output. During the observed procedure, a CNA, assisted by the ADON and an RN, placed soiled washcloths back into containers of clean soapy water and reused the contaminated water for further cleansing of the catheter site. The resident was also left exposed during the procedure, and a blanket with visible hairs was used to cover the resident afterward. Interviews with the ADON, CNA, and RN confirmed that soiled washcloths should not have been placed back into clean water basins, and that this practice contaminated the water used for catheter care. The CNA acknowledged the error but was unsure if it occurred during the observed procedure, while the RN confirmed witnessing the contamination. These actions were inconsistent with established infection control protocols and the facility's own policies for catheter care.