Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
A deficiency occurred when a registered nurse (RN) failed to follow established infection prevention and control protocols during the care of a male resident who was newly admitted and receiving antibiotic therapy for a urinary tract infection (UTI) and had a suprapubic catheter and a midline IV. The resident was on Enhanced Barrier Precautions (EBP) as ordered by the physician, which required the use of gloves and a gown during high-contact care activities such as incontinence care and device care. Despite these orders and facility policy, the RN did not wear a gown while providing incontinence care and failed to change gloves between removing a soiled brief and applying a clean one. The RN also did not perform hand hygiene or change gloves between different care tasks, including cleaning the resident’s suprapubic catheter. During the observed care, the RN used the same gloves and wipes for multiple steps, including cleaning the resident’s perineal area, changing briefs, and cleaning the suprapubic catheter. The catheter was cleaned in a manner inconsistent with facility policy, as the RN cleaned towards the insertion site rather than away from it, increasing the risk of contamination. The RN also replaced the resident’s bedding while still wearing the same contaminated gloves. In interviews, the RN acknowledged forgetting to wear the required PPE and to change gloves, attributing this to the absence of a PPE cart and the resident being a new admission. The RN also admitted not considering the infection control implications of her actions. Facility policies reviewed included clear instructions for EBP and indwelling catheter care, specifying the use of gowns and gloves for high-contact activities and the correct technique for cleaning catheters. The Director of Nursing (DON) confirmed that staff are expected to follow these protocols, including changing gloves between dirty and clean tasks and cleaning catheters from the insertion site outward. The observed failures to adhere to these protocols were confirmed through interviews and record reviews, demonstrating a breakdown in the facility’s infection prevention and control program for this resident.