F0880

F

Infection Control Lapses with EBP, Catheter Care, Hand Hygiene, and Medication Cart Sanitation

Chicago, Illinois Survey Completed on 12-04-2025

Penalty

No penalty information released

Summary

Surveyors identified multiple failures in the facility’s infection prevention and control practices involving residents on Enhanced Barrier Precautions (EBP), residents with indwelling urinary catheters, and during meal and medication passes. One resident with severe cognitive impairment, bowel and bladder incontinence, and an indwelling urinary catheter was on EBP with a posted sign and a PPE cart containing gowns and gloves outside the room. Despite this, a registered nurse entered the resident’s room without performing hand hygiene or donning gown and gloves, then provided high-contact care including assisting the resident from the bathroom to bed, touching the resident’s hands, arms, and urinary catheter, and handling the resident’s nasal cannula. During this care, the nurse dropped the nasal cannula tubing on the floor and then placed it back on the resident without changing it or performing hand hygiene, and exited the room after scratching their own face, again without hand hygiene. The nurse later acknowledged that residents with catheters or wounds are placed on EBP and that PPE and hand hygiene should be used during high-contact care, and admitted not following these practices.

Surveyors also observed failures in hand hygiene during meal service. A CNA removed a used cup from in front of one resident, discarded it in the trash, and then immediately obtained a bowl of soup and placed it in front of another resident without performing hand hygiene between residents. The CNA later stated that the first resident had put soup in the juice cup, that she discarded the cup for that reason, and that she did not sanitize her hands between residents but should have, acknowledging that hand hygiene is part of being sanitary. Additionally, the facility’s own hand hygiene policy required hand hygiene with alcohol-based hand rub immediately prior to touching a resident, when caring for a resident, after touching a resident or the resident’s environment, and after removal of gloves and PPE, and required soap and water after contact with body fluids or contaminated surfaces.

Further infection control lapses were observed related to urinary catheter management and medication cart sanitation. One resident with a urinary catheter was observed in bed with fall mats on both sides and the catheter drainage bag on the floor containing approximately 400 ml of yellow urine; the bag was affixed to a non-movable part of the bed frame but was touching the floor and was not in a privacy bag. Nursing staff, including an LPN and the RN, confirmed that catheter bags should be hung on a non-movable part of the bed, not touching the floor, and that they should be in a privacy bag, with the LPN noting that the bag should drain to gravity and not sit on the floor to prevent backflow of urine which can cause urinary tract infection. In another instance, an LPN placed a reusable white foam tray on a resident’s dresser, then removed it and placed it on top of the medication cart without cleaning it. The LPN stated the tray is disposable but used throughout the shift and that he should have wiped it off before bringing it out of the resident’s room. The DON stated that such trays can be reused only if sanitized between uses and that the medication cart would be considered contaminated when a used, unsanitized tray is placed on it.

The facility’s policies and job descriptions further outlined expectations that were not followed in these events. The Enhanced Barrier Precautions documents required everyone to clean hands before entering and when leaving the room and required staff to wear gloves and gowns for transferring, assisting with toileting, and urinary catheter care for residents with indwelling medical devices. The EBP policy specified that gown and gloves must be used prior to high-contact care activities such as dressing, transferring, providing hygiene, assisting with toileting, and device care, and that hand hygiene should be performed prior to entering and exiting the room when not providing high-contact care. The staff nurse job description required nurses to ensure nursing procedures and protocols are followed in accordance with established policies, and the DON job description required the DON to assure all nursing procedures and protocols are followed and to make daily rounds to ensure appropriate procedures are being followed. Despite these written expectations, surveyors observed multiple instances where staff did not perform required hand hygiene, did not use PPE during high-contact care for residents on EBP, allowed a urinary catheter bag to rest on the floor, and failed to sanitize reusable trays before placing them on the medication cart.