Failure to Remove PPE and Maintain Catheter Hygiene During Resident Transport
Penalty
Summary
Staff failed to implement the Infection Prevention and Control Program (IPCP) by not properly removing personal protective equipment (PPE) after providing resident care and by allowing indwelling catheter tubing to contact the floor during resident transport. Specifically, a physical therapy assistant was observed wearing PPE while assisting a resident in his room and then transporting him in a wheelchair to the shower room without removing the gown. During this transport, the resident’s indwelling catheter tubing was observed in contact with the floor. The staff member admitted to keeping the gown on because she anticipated needing it again for further care in the bathroom and was unaware that the catheter tubing had touched the floor. The resident involved had multiple diagnoses, including atrial fibrillation, heart failure, diabetes, thyroid disorder, arthritis, stroke, urinary tract infection, and acute cystitis with hematuria, and was dependent on staff for all activities of daily living and mobility. Facility policies required staff to remove PPE before exiting a resident’s room and to ensure catheter tubing and drainage bags were kept off the floor. Interviews with the infection preventionist and director of nursing confirmed that staff should have removed PPE before leaving the resident’s room, and policy review indicated that enhanced barrier precautions should be followed in certain situations outside the resident’s room, but not in hallways unless specific care activities were being performed.