Failure to Change Gloves and Perform Hand Hygiene During Catheter Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control practices during urinary catheter care for one resident. During a survey observation, a CNA donned a clean gown and gloves, pulled down the resident's sweatpants, and performed catheter care. After completing the catheter care, the CNA did not remove the soiled gloves. With the same gloves still on, the CNA pulled up the resident's sweatpants, pulled up the right pant leg, opened an alcohol wipe, and cleaned the spout of the leg bag. The CNA then emptied urine from the leg bag, used another alcohol wipe on the spout, dumped the urine in the toilet, pulled down the resident's pant leg over the catheter bag, and adjusted the resident's blankets, only removing the gloves at the end of all these tasks. The facility's hand hygiene policy required staff to comply with CDC hand hygiene guidelines, including performing hand hygiene before donning gloves and after removing gloves, and changing gloves during resident care when moving from a contaminated body site to a clean body site. The policy also stated that all personnel receive training and competency validation on hand hygiene at the time of employment. The CNA later acknowledged that it made sense to remove gloves after catheter care and confirmed that she had forgotten to do so. An administrative nurse confirmed that the CNA should have removed her gloves after catheter care, sanitized her hands, and then put on a clean pair of gloves, consistent with the facility's policy.
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