Infection Control Failures in Hand Hygiene, Catheter Care, and COVID-19 Protocols
Penalty
Summary
Staff failed to perform hand hygiene at appropriate intervals during the provision of care, specifically when removing soiled gloves and before donning clean gloves. Observations showed that nurse aides did not complete hand hygiene before putting on personal protective equipment or after removing gloves during catheter care and incontinence care for a resident. The urinary catheter drainage bag was repeatedly placed on bed linens and positioned above the level of the resident's bladder and head during transfers, contrary to facility policy and best practices for infection prevention. The resident involved had multiple medical conditions, including heart failure, previous stroke with paralysis, sepsis, obstructive uropathy, anxiety, depression, and diabetes. The resident required total staff assistance for hygiene and had an indwelling urinary catheter. During care, the catheter drainage bag was handled inappropriately, including being placed on the bed and attached to the lift above the resident's bladder, and staff did not consistently perform hand hygiene between glove changes while managing incontinence and catheter care. Additionally, the facility failed to follow its COVID-19 protocols. The DON was observed with respiratory symptoms but had not completed a COVID-19 test and stated there was no intention to do so. It was confirmed by a registered nurse that the facility did not test staff or residents presenting with respiratory symptoms or increased temperature, despite facility policy requiring symptomatic employees to be restricted from work until COVID-19 infection was ruled out by testing.