Failure to Perform Hand Hygiene During Catheter Care
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices during indwelling catheter care for a male resident with benign prostatic hyperplasia. During an observed care episode, two CNAs donned gowns and gloves before entering the resident's room. One CNA assisted the resident with transferring to bed and removing clothing, then initiated catheter care without changing gloves or performing hand hygiene. After cleansing the resident's thigh creases, the CNA disposed of soiled gloves but did not perform hand hygiene before donning new gloves. This process was repeated after cleansing the catheter tubing, with gloves changed but no hand hygiene performed between changes. Interviews with the involved CNAs and the DON confirmed that hand hygiene should have been performed between all glove changes, as per facility policy. The facility's standard precautions policy requires hand hygiene before and after resident contact and after removing gloves. The failure to follow these procedures was observed and acknowledged by staff, and the DON confirmed that not adhering to hand hygiene protocols could result in the spread of infection.