Failure to Follow Infection Control Practices for Wound Care and Catheter Management
Penalty
Summary
The facility failed to adhere to its infection prevention and control policies for three residents reviewed for infection control. For one resident with a stage two pressure ulcer, staff did not implement Enhanced Barrier Precautions (EBP) during wound care. Despite having physician orders and a care plan intervention for EBP, staff performed wound care without donning gowns, and there was no EBP sign posted on the resident's door. Both the Registered Nurse and the RN Clinical Competency Coordinator acknowledged that EBP, including gown and glove use, should have been followed due to the open wound, but it was not implemented at the time of care. For two other residents with indwelling urinary catheters, the facility failed to ensure that catheter bags were kept off the floor. One resident with a Foley catheter was observed twice with the catheter bag in contact with the floor, once while in bed and again while seated in a wheelchair. Another resident with a suprapubic catheter was observed with the catheter bag resting on the ground while in bed. Both residents had care plans and physician orders addressing catheter care and the prevention of complications, but the required infection control practice of keeping catheter bags off the floor was not followed. Staff interviews confirmed awareness of the infection control requirements, including the need for EBP during wound care and the importance of keeping catheter bags off the floor to prevent contamination and infection. The Director of Health Services verified that the residents' care plans and orders included the necessary precautions, and staff acknowledged the lapses in following established infection control protocols.