Failure to Follow Hand Hygiene and Infection Control Procedures During Catheter Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding hand hygiene and glove use during suprapubic catheter care for two residents. During catheter care for one resident with a history of acute cystitis and an indwelling suprapubic catheter, an LVN applied a clean dressing without sanitizing her hands or changing gloves after cleaning the catheter site. This was observed directly and later confirmed in an interview, where the LVN acknowledged forgetting to perform hand hygiene and glove change before dressing application. In a separate incident, an RN initiated catheter care for another resident with a suprapubic catheter and flaccid hemiplegia without washing or sanitizing her hands prior to donning gloves. The RN also failed to remove gloves and perform hand hygiene throughout the procedure, including before applying a clean dressing. The RN admitted in an interview that she forgot to wash or sanitize her hands before starting care and before dressing application, recognizing the potential for infection as a result. The Director of Nursing confirmed that there was no specific procedure for suprapubic catheter care beyond routine ADL care, but stated that her expectation was for staff to perform hand hygiene before care, after removing dirty gloves, and before applying clean dressings. Facility policy also required hand hygiene before resident contact, before donning gloves, and after glove removal, emphasizing that glove use does not replace hand hygiene. These lapses in following established hand hygiene protocols were observed and acknowledged by the staff involved.