Failure to Follow Hand Hygiene Protocol During Catheter Care
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to follow proper infection control practices during catheter care for a resident with an indwelling urinary catheter. The CNA was observed double-gloving before entering the resident's room and did not clean the bedside table before setting up supplies. During the catheter care process, the CNA removed only the outer pair of gloves after cleaning the catheter insertion site but continued the remainder of the care, including rinsing, drying, and repositioning the resident, with the same inner gloves. At no point during the procedure did the CNA wash or sanitize her hands when transitioning between clean and dirty tasks, nor did she don new gloves as required by facility policy and professional practice standards. The resident involved had a history of urinary retention, severely impaired cognition, and was dependent on staff for all activities of daily living. The resident's care plan did not include specific interventions for the indwelling urinary catheter, despite physician orders outlining catheter care and enhanced barrier precautions. Facility policy and audit tools specifically required hand hygiene and glove changes during catheter care, but these protocols were not followed during the observed incident.