Inadequate Infection Control for Catheter Care, Hand Hygiene, and Oxygen Tubing
Penalty
Summary
The deficiency involves failures in infection prevention and control practices related to hand hygiene, use of PPE under Enhanced Barrier Precautions (EBP), management of indwelling urinary catheters, and handling of respiratory equipment. One resident with an indwelling urinary catheter was on EBP, as indicated by a sign on the door and a PPE bin that contained no gowns. Surveyors observed the resident in bed with the catheter drainage bag attached to the bed, and later in the dining room with the catheter bag hanging outside the dignity bag and touching the floor. When the resident was assisted back to her room, the catheter bag continued to drag on the floor as the wheelchair was pushed. During morning care, a CNA placed the catheter bag on the floor while draining urine from the tubing into the bag, then temporarily hung the bag above the level of the bladder on the footboard before another CNA repositioned it below bladder level. Throughout peri-care, brief change, dressing, and use of a mechanical lift, the CNAs did not perform hand hygiene, did not change gloves after contact with soiled areas, and did not wear gowns despite the resident being on EBP and having an indwelling catheter. Another resident using oxygen had her oxygen tubing wrapped around the handle of her wheelchair while she was in bed with oxygen in use, and this condition persisted on subsequent observation. A CNA reported that when assisting residents with oxygen, she typically wound the tubing and laid it on a surface and was unaware of any bag or sanitary container for storing the tubing. Staff interviews revealed gaps in knowledge and practice expectations: one CNA stated she did not know gloves had to be changed and hand hygiene performed during care after touching something dirty, and she was unsure about gown use for a resident with a catheter. The licensed nurse and administrative nurse both stated their expectations that catheter bags remain below bladder level, never touch the floor, that staff perform hand hygiene and change gloves after contact with contaminated areas, and that oxygen tubing be kept in a bag when not in use, consistent with facility policies on catheter care and hand hygiene.
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