Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for two residents observed for infection control. For one resident with multiple sclerosis and a neurogenic bladder, who had an indwelling urinary catheter and was on Enhanced Barrier Precautions, a registered nurse did not use the required personal protective equipment (PPE) while changing the suprapubic catheter. Specifically, the nurse wore gloves but did not don a gown as required by the facility's Enhanced Barrier Precautions policy, despite signage and available PPE in the resident's room. The nurse acknowledged the oversight and confirmed understanding of the required precautions for residents with indwelling medical devices. In a separate incident, a certified nursing assistant (CNA) did not follow proper glove and hand hygiene protocols while providing incontinence care to another resident. The CNA changed gloves without performing hand hygiene and, at one point, used soiled gloves to place a clean brief under the resident. The CNA also assisted the resident with dressing and transferring without changing gloves or performing hand hygiene between tasks. The CNA later stated awareness of the correct procedures but did not realize the lapse during care. Both incidents were observed directly by surveyors and confirmed through interviews with the involved staff and the Director of Nursing. Facility policies on Enhanced Barrier Precautions, perineal care, and hand hygiene were reviewed and found to require the use of gowns and gloves for certain care activities and hand hygiene between glove changes, which were not followed in these cases.