Failure to Implement Effective Infection Control and Catheter Care Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of COVID-19 testing for staff members exhibiting symptoms consistent with communicable diseases. Despite the facility's policy requiring surveillance and control of infections for all individuals, documentation showed that multiple staff members returned to work after experiencing symptoms such as nausea, vomiting, diarrhea, fever, sore throat, cough, and cold symptoms without being tested for COVID-19. Interviews with the Director of Nursing (DON) and Infection Preventionist (IP) revealed uncertainty regarding the criteria for testing symptomatic staff, and both confirmed that symptomatic staff had not been tested as required by CDC guidance and facility policy. Additionally, the facility failed to follow proper infection control procedures during catheter care for a resident with a diagnosis of neurogenic bladder. During an observed care episode, a Certified Nursing Assistant (CNA) used a soiled washcloth to clean the catheter insertion site and then used a contaminated alcohol wipe, which had been dropped on the floor, to disinfect the distal end of the catheter before connecting it to a leg bag. The CNA acknowledged that these actions were not acceptable, and the interim DON agreed with this assessment when informed of the observations. The deficiencies identified had the potential to affect all residents in the facility, as the lack of proper infection surveillance and control measures could contribute to the development and transmission of communicable diseases, including COVID-19. The improper catheter care practices also posed a risk of infection for the resident involved, who was cognitively intact and required catheter care every shift as ordered by a physician.