Failure to Follow Infection Control Practices During Resident Care
Penalty
Summary
Surveyors observed multiple failures in infection prevention and control practices among staff caring for three residents with urinary catheters and incontinence needs. In one instance, a CNA donned gloves and PPE to assist a resident with morning care, including changing an incontinence brief and dressing the resident, but did not change gloves between different care activities. The CNA also placed the resident's full urinary catheter drainage bag directly on the floor, both before and after care. In another case, two CNAs changed a resident's soiled incontinence brief, with one CNA repeatedly obtaining gloves from his uniform pocket and not consistently performing proper hand hygiene between glove changes. The gloves stored in the uniform pocket were not considered clean, and hand sanitizer was not used according to facility policy, as it was wiped off with a washcloth instead of being rubbed until dry. A third resident was observed with a full urinary catheter drainage bag left on the floor for several hours. When two CNAs later assisted with care, one obtained gloves from his uniform pocket and did not change gloves or perform hand hygiene between different care activities, including cleaning the catheter tubing, peri-area, and dressing the resident. Both CNAs failed to change gloves and perform hand hygiene as required. Facility policies reviewed by surveyors specified that gloves should be single-use and not stored in uniforms, hand hygiene should follow CDC guidelines, and catheter drainage bags should always be kept off the floor. The Assistant Director of Nursing confirmed staff expectations for proper glove use, hand hygiene, and catheter care, which were not followed in these instances.