Failure to Follow Infection Control Practices During Wound Care and Catheter Management
Penalty
Summary
A deficiency was identified when a resident with quadriplegia, a flaccid neuropathic bladder requiring a urinary drainage bag, and a stage 4 pressure ulcer did not receive care in accordance with infection control protocols. During wound care, an LPN failed to don a gown as required under Enhanced Barrier Precautions (EBP) for hands-on care of residents with open wounds. The LPN also used the same pair of soiled gloves to handle multiple medication tubes and returned these medication containers to a shared wound cart without disinfecting them. Additionally, the LPN brought medication containers into the resident's room, contrary to facility policy, which states that such items should not enter resident rooms to prevent cross-contamination. Further observations revealed that the resident's urinary drainage bag was resting on the floor rather than being secured to an appropriate holder, and was subsequently placed on the resident's bed prior to wound care. Facility staff, including the Infection Preventionist and Director of Nursing, confirmed that these actions were inconsistent with established infection control practices, which require the use of gowns and gloves for EBP, proper handling of medication containers, and ensuring urinary drainage bags are kept off the floor to prevent infection.