Failure to Follow Infection Control Protocol During Suprapubic Catheter Care
Penalty
Summary
A deficiency was identified when a registered nurse failed to follow proper infection control procedures while providing wound and suprapubic catheter care to a resident with multiple complex medical conditions, including muscular dystrophy, respiratory failure, dysphagia, malnutrition, and a suprapubic catheter. During observation, the nurse performed two wound treatments and then proceeded to change the suprapubic catheter dressing without changing gloves between procedures. The nurse also cleansed the catheter insertion site by repeatedly wiping the same area with the same part of the gauze pad, contrary to facility policy, which requires using a new cotton ball or applicator for each outward stroke from the stoma. The resident's clinical record revealed an incident where the resident was found with blood in the urine and large sediment in the catheter tubing, resulting in a transfer to the emergency room. Subsequent laboratory testing confirmed a urinary tract infection with a high bacterial count. Facility policy and infection control expectations, as confirmed by the Infection Control Preventionist, require hand hygiene, glove changes, and proper technique when cleaning the suprapubic catheter site, which were not followed during the observed care.