Failure to Perform Hand Hygiene and Glove Change During Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to perform appropriate hand hygiene and glove changes during suprapubic catheter site care for a resident. The RN performed hand hygiene and donned personal protective equipment upon entering the room, but after removing the old dressing from the catheter site, did not change gloves or perform hand hygiene before cleaning the site and applying a new dressing. The RN only performed hand hygiene after completing the procedure and removing personal protective equipment. This practice was observed directly by the surveyor. Additionally, the facility did not have a specific policy in place to guide staff on the care of suprapubic catheter sites. The existing hand hygiene policy was undated and only provided general guidance on when hand hygiene should be performed, such as after handling contaminated objects or before invasive procedures. Interviews with facility staff confirmed that hand hygiene and glove changes should occur after removing a soiled dressing and before applying a new one, but this was not followed during the observed care. The resident involved was cognitively intact and had a history of multiple sclerosis, neuromuscular bladder dysfunction, and an appendicovesicostomy.