Failure to Follow Proper Catheter Care and Infection Prevention Protocols
Penalty
Summary
Staff failed to provide appropriate catheter care and infection prevention for two residents with indwelling urinary catheters. In one instance, a CNA performed suprapubic catheter care without following proper hand hygiene protocols, such as not changing gloves or performing hand hygiene when moving from dirty to clean tasks, and failed to use a barrier under the wash basin. The CNA also contaminated the wash basin by reaching into it with soiled gloves and admitted to not following correct procedures during an interview. The DON confirmed that hand hygiene should be performed before and after care and when moving from dirty to clean, and that a barrier should be used under the wash basin. In another case, an LPN provided catheter care to a resident with a history of chronic kidney disease, pyelitis cystica, and obstructive uropathy. The LPN did not don a gown, failed to change gloves or perform hand hygiene after picking up a cleansing wipe that had fallen into the toilet, and continued care without following standard precautions. The resident was found with urine-soaked clothing due to the catheter not being attached to the leg bag, and the stat lock and extension tubing were missing. The LPN admitted to not knowing the facility's catheter care policy and acknowledged that gloves should have been changed after handling the contaminated wipe. Facility policy and CDC guidelines require hand hygiene and standard precautions, including glove changes and the use of barriers, during catheter care to prevent infection. Both staff members failed to adhere to these protocols, as evidenced by their actions and their own admissions during interviews. The DON also stated that she teaches staff to triple glove and remove layers as they become soiled, but was unsure if this practice aligns with CDC recommendations.