Improper Infection Control During Catheter and Perineal Care
Penalty
Summary
The deficiency involves failures in infection control and proper catheter/perineal care for two residents during incontinence care. One resident with a history of urinary retention and prior UTIs, who was cognitively intact and dependent on staff for most ADLs including toileting, reported fear of getting another UTI and stated staff did not always clean her as often as they should. During observed catheter and perineal care, a CNA provided front perineal care, then walked to the other side of the bed to perform perianal care without changing gloves or performing hand hygiene after handling the trash can. The CNA also did not cleanse the resident’s catheter tubing during care. The CNA later acknowledged she had cross-contaminated the perianal area by not changing gloves and that she should have cleansed the catheter tubing to the junction of the drainage bag tubing. For a second cognitively intact resident with multiple medical diagnoses including CHF, DMII, and a history of UTI, a CNA prepared supplies for catheter/perineal care and had a glove box with several gloves protruding from the top. The CNA accidentally knocked the glove box to the floor, then picked it up, washed her hands, and obtained gloves from the same box to perform catheter/perineal care. The CNA used these potentially contaminated gloves while providing care. During this care, the CNA observed and verbally noted that the resident’s penis was very red, swollen, and sore, and the resident confirmed soreness. The DON later stated that staff should not cross-contaminate during perineal care, that gloves or items that touch the floor are considered contaminated and should not be used, and that existing incontinence/catheter/perineal care policies did not address these specific concerns, although the expectation was that staff would avoid cross-contamination of residents’ perineal areas.
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