Failure to Follow Infection Control Protocols During Catheter Care
Penalty
Summary
The facility failed to ensure proper infection control measures were followed during catheter care for a resident with an indwelling catheter and a history of dementia, benign prostatic hyperplasia, and obstructive and reflux uropathy. The resident required significant assistance with activities of daily living and was frequently incontinent of bowel. During an observation, a CNA provided peri and catheter care using the same wash cloths for both the resident's frontal peri area and backside, where there had been a bowel movement. Additionally, the CNA did not change gloves during the care process and touched multiple items in the resident's environment, including the bed control, sheets, the resident's head, and pillow, with soiled gloves. The CNA confirmed in an interview that she did not change gloves until after care was completed and used the same wash cloths for both areas. Facility policy required hand hygiene at key points, including after contact with body fluids or contaminated surfaces and after removing gloves, but these procedures were not followed.