F0880

E

Failure to Follow Hand Hygiene, Catheter Care, and Enhanced Barrier Precautions

Gallup, New Mexico Survey Completed on 12-05-2025

Penalty

No penalty information released

Summary

The deficiency involves multiple failures in the facility’s infection prevention and control practices, beginning with improper hand hygiene during medication administration. During a morning medication pass, a certified medication aide administered a resident’s medications and then immediately returned to the medication cart to document and prepare the next resident’s medications without performing hand hygiene. In an interview, the aide acknowledged she forgot to perform hand hygiene and confirmed that facility infection control policy requires hand hygiene after each medication administration.

The facility also failed to maintain proper catheter tubing management for two residents with indwelling urinary catheters. One resident with a history of malignant neoplasm of the kidney, benign prostatic hyperplasia, and severe cognitive impairment (BIMS score of 6) had an active order for an indwelling Foley catheter for chronic urinary retention or incontinence with discomfort. On multiple observations in the dining room and hallway, this resident’s catheter tubing was seen dragging across the floor as he propelled himself in his wheelchair. Staff interviews, including with an LPN, the DON, and the Administrator, confirmed that catheter tubing should not drag on the floor because it could cause infection or be pulled out, and that their expectation was that tubing be properly secured below the bladder and off the ground. A second resident with dementia, history of traumatic brain injury, adult failure to thrive, and severe cognitive impairment (BIMS score of 2) was observed seated in a wheelchair with the drainage bag in a privacy bag off the floor, but the catheter tubing between the resident and the bag was routed under the wheelchair and dragging on the floor. Staff again confirmed this should not occur and reiterated expectations that catheter tubing be secured and not touch the ground.

The facility further failed to implement Enhanced Barrier Precautions (EBP) and appropriate PPE disposal for residents with indwelling devices and wounds. The facility’s EBP policy required gown and glove use during high-contact resident care activities for residents with wounds or indwelling devices, posting of EBP signage, and use of appropriate receptacles for contaminated PPE. One resident on EBP had signage posted on the room door, but there was no red biohazard or designated bin in the room, only a single trash can shared by both roommates. During care, the ADON and a medical records staff member transferred this resident from wheelchair to bed without using PPE, and the ADON later stated she was unsure of the EBP policy, whether she should have been following EBP during that care, and how PPE should be disposed of. Another resident with a surgical wound, Foley catheter, and care plan specifying EBP (including gown and glove use for high-contact activities and changing PPE before caring for another resident) had EBP signage posted, but repeated observations showed no biohazard bin in the room or on the hall, despite reusable gowns being available. On multiple occasions, RNs provided care to this resident without wearing PPE, and in interviews they acknowledged the resident was on EBP, that they were not using proper PPE, that there were no biohazard bins in the room, and that their expectation was for staff to follow EBP and have appropriate bins available for PPE disposal.

Across these observations, the facility did not ensure staff consistently followed its own infection control policies for hand hygiene, catheter care, and EBP implementation. Staff at various levels, including direct care staff and nursing leadership, either did not follow or were uncertain about EBP requirements, and rooms designated for EBP lacked appropriate biohazard or designated bins for contaminated PPE disposal. These actions and inactions resulted in the cited infection prevention and control deficiency for the residents reviewed.