Failure to Implement Infection Control Practices During Wound and Catheter Care
Penalty
Summary
The facility failed to ensure staff consistently and correctly implemented infection control practices, specifically regarding enhanced barrier precautions (EBP) during wound care and proper catheter care and hand hygiene. During wound care for a resident with a history of MRSA infection and a central line, an LPN performed hand hygiene and donned gloves but did not wear an isolation gown as required by the facility's EBP policy. The LPN was unable to state whether a gown was necessary and noted the absence of PPE setup outside the resident's room, despite a caddy with PPE being present. The resident's care plan and physician orders clearly indicated the need for EBP, including gown and glove use during high-contact care activities such as wound care. In two separate observations of catheter care, staff did not follow proper infection control protocols. For one resident with an indwelling catheter, a GNA failed to sanitize the bedside table or use a barrier before placing supplies, did not change gloves or perform hand hygiene during the procedure, and cleaned the catheter in the incorrect direction. The GNA acknowledged not changing gloves or performing hand hygiene and stated that gloves would only be changed if they ripped or became soiled. For another resident with an indwelling catheter, a different GNA also failed to sanitize the nightstand or use a barrier, did not change gloves or perform hand hygiene after providing catheter care, and continued to handle the resident's personal items and assist with grooming while still wearing the same gloves. This GNA was unaware of the need to change gloves and perform hand hygiene at specific points during the procedure. Interviews with the Infection Preventionist, Interim DON, and Regional Director of Operations confirmed expectations that staff should follow EBP and hand hygiene protocols. However, the Infection Preventionist admitted to only occasionally observing staff during wound and catheter care, and the staff involved were either unaware of or did not adhere to the required infection control practices. The facility's own policies on EBP, hand hygiene, and catheter care were not followed during the observed care activities, leading to the identified deficiencies.