Failure to Maintain Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain appropriate infection control practices, specifically in the care of residents with indwelling urinary catheters and chronic wounds. In one instance, a registered nurse provided catheter care to a resident with multiple complex medical conditions, including Parkinson's disease, chronic kidney disease, and a history of urinary tract infections. During the procedure, the nurse did not change gloves or perform hand hygiene after cleansing the resident's rectal area and before cleaning the indwelling urinary catheter, despite facility policy requiring hand hygiene when moving from a soiled to a clean body site. Additionally, the resident's catheter collection bag was observed lying on the floor, which was acknowledged by the nurse as a potential infection risk. In another case, a nurse performed a dressing change for a resident with a chronic scalp wound and multiple comorbidities such as diabetes, heart failure, and a history of skin picking. Although the nurse followed hand hygiene and glove use protocols during the dressing change, Enhanced Barrier Precautions (EBP) were not implemented as required by the resident's care plan and physician orders. The Director of Nursing confirmed that EBP were not utilized during the dressing change, and there were no orders for EBP in place for this resident at the time of the observation. Facility policy reviews indicated that both hand hygiene and EBP are essential components of infection prevention and control, particularly for high-contact care activities such as wound care and device management. The observed lapses in infection control practices and failure to implement EBP during resident care directly contributed to the identified deficiencies.