Failure to Follow Infection Control Practices During Incontinent and Catheter Care
Penalty
Summary
The facility failed to ensure that two residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections (UTIs) and to restore continence to the extent possible. For one resident with a history of frontotemporal neurocognitive disorder, Down syndrome, paraplegia, and neuromuscular dysfunction of the bladder, a CNA did not follow proper infection control practices during catheter and incontinent care. The CNA did not clean or place a barrier on the bedside table before placing supplies, failed to change gloves and perform hand hygiene when moving from dirty to clean tasks, and handled clean items after touching soiled materials without changing gloves. The CNA acknowledged these lapses during an interview, stating he should have changed gloves and performed hand hygiene at multiple points during care. For another resident with multiple sclerosis, neurogenic bladder, and a history of recurrent UTIs, a different CNA also failed to follow infection control protocols during incontinent care. The CNA washed her hands and donned gloves initially but did not perform hand hygiene when changing gloves between dirty and clean tasks. She also handled clean linens without changing gloves after providing care to soiled areas. The CNA admitted she should have used hand sanitizer and changed gloves at appropriate times but did not have sanitizer available and became distracted during care. Both residents had care plans and physician orders addressing their incontinence, catheter use, and risk for UTIs, including specific medications and interventions. Despite documented competency evaluations for the CNAs, direct observation revealed that infection control practices were not consistently followed during care. Facility leadership confirmed their expectations for proper hand hygiene and glove use during such care, and acknowledged the importance of these practices in preventing infection.