Infection Control Lapses in Catheter Management and Hand Hygiene
Penalty
Summary
Surveyors identified failures in the facility’s infection prevention and control practices involving residents with Foley catheters and during personal care. For one resident on enhanced barrier precautions (EBP) due to a Foley catheter, signage outside the room indicated EBP was required. During observations, the resident’s catheter drainage bag was clipped to the wheelchair with the catheter tubing resting on the floor in the room and later in the dining room. A CNA emptied the catheter drainage bag while wearing gloves but left the catheter tubing dragging on the floor when exiting the room. Record review showed the resident had neuromuscular dysfunction of the bladder and prostatic hyperplasia, with physician orders for catheter care every shift and EBP due to the Foley catheter. Facility policy for emptying Foley catheters required standard precautions and aseptic technique, and the isolation policy required that protective equipment be maintained near the resident’s room for use when transmission-based precautions are implemented. The Infection Control Preventionist stated that catheter tubing should be kept off the floor whenever possible and that staff should don gloves and a gown when providing catheter care for residents on EBP due to a Foley catheter. In a separate observation involving another resident, a CNA assisted the resident to the restroom and removed a soiled brief while the resident was on the commode. After disposing of the soiled brief, the CNA removed their gloves and donned a new pair of gloves from a container without performing hand hygiene in between glove changes. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of infections and required the use of alcohol-based hand rub or soap and water after removing gloves, as well as performing hand hygiene before applying non-sterile gloves. The Infection Control Preventionist confirmed that staff should perform hand hygiene before donning new gloves and between glove changes.
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