Failure to Maintain Infection Control Practices During Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for two residents reviewed for infection control. In the first instance, a resident with neuromuscular dysfunction of the bladder and an indwelling catheter was observed being transferred from a wheelchair to a bed by a CNA. During the transfer, the CNA placed the resident's catheter bag on the floor, outside of its privacy bag, before completing the transfer and then hanging the bag on the bed rail. The CNA later acknowledged that the catheter bag should not have been placed on the floor due to the risk of contamination. In the second instance, another resident with muscle weakness and total incontinence was provided incontinent care by two CNAs. During the care, one CNA changed gloves after cleaning the resident's perineal area and bottom but did not perform hand hygiene before donning a new pair of gloves, which she retrieved from her pocket. The CNA admitted that she did not sanitize her hands between glove changes and recognized that gloves stored in her pocket could be contaminated. Facility policy reviews confirmed that catheter bags should be kept off the floor and that hand hygiene must be performed after glove removal and before donning new gloves. The observed actions by staff were inconsistent with these policies, resulting in a failure to prevent potential cross-contamination and infection among residents.