Failure to Maintain Infection Control During Bowel and Bladder Care
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices during bowel and bladder care for a resident with hemiplegia and a gastrostomy tube. On several occasions, staff did not maintain proper hygiene or aseptic technique. The resident was observed sitting directly on their feeding tube tubing while using a bedside commode. A LPN disconnected the tubing, removed it from under the resident, hung it back on the feeding pole, and then reconnected it to the feeding tube port without changing the tubing. Additionally, a CNA cleaned the resident's rectal area after a bowel movement and, without changing dirty gloves, handed the resident a washcloth and applied cream to the resident's buttock. The resident confirmed that the tube feeding was reconnected without the tubing being changed. Further observations included a CNA bringing a clear garbage bag of washcloths from the bathroom, using a washcloth from the bag to clean the resident, and then dropping the bag so that washcloths fell onto the floor. The CNA then picked up a washcloth from the floor and handed it to the resident for peri care. The CNA stated the washcloths were clean. The resident was cognitively intact, required partial to moderate assistance with toileting hygiene, and was frequently incontinent. These actions demonstrate a lack of adherence to infection control protocols during personal care and handling of medical equipment.