Failure to Follow Infection Control Procedures During Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control procedures were followed during care for a resident with an indwelling urinary catheter. During observation, a certified nurse aide (CNA) performed catheter and incontinence care without adhering to established protocols. The CNA used wet washcloths placed directly on an unclean overbed table, did not use a barrier or basin, and failed to clean the catheter insertion site appropriately. The same gloves were used throughout the care process, including handling clean and soiled items, and the CNA did not change gloves or perform hand hygiene at appropriate intervals. Additionally, the CNA exited and re-entered the resident's room while still wearing the same gown and gloves used during care, and handled clean items after touching soiled materials without proper glove changes or hand hygiene. Further deficiencies were observed in the handling of soiled linens and personal protective equipment (PPE). The CNA placed soiled washcloths and briefs on the floor next to the resident's bed and in the bathroom doorway, rather than immediately disposing of them in appropriate bags. The CNA also failed to have trash bags ready prior to care, as required by facility policy. After completing care, the CNA walked through the hallway and accessed clean linen and medication carts while still wearing the soiled gown and gloves, further breaching infection control protocols. Only after these actions did the CNA perform hand hygiene and properly dispose of PPE and soiled items. Interviews with staff confirmed that the observed practices were inconsistent with facility policies and standard infection control procedures. Staff acknowledged that basins and clean washcloths should be used, soiled items should never be placed on the floor, and PPE must be removed before exiting a resident's room. Hand hygiene was also confirmed as a required step before and after glove changes. Review of facility policies corroborated these requirements, including proper cleaning of the catheter insertion site, appropriate disposal of soiled linens, and correct donning and doffing of PPE. The failure to follow these procedures was observed to affect one resident directly and had the potential to impact all residents on the unit.