Failure to Follow Infection Control Practices for Indwelling Devices and Medication Administration
Penalty
Summary
Surveyors identified failures in infection prevention and control practices involving a resident with an indwelling urinary catheter and G-tube, and another resident during medication administration. For Resident 6, observations on multiple occasions showed the urinary catheter drainage bag hanging so that several inches of the bag were in direct contact with the floor, with no clean barrier in place. The resident’s bed was positioned against the wall, and staff left the catheter bag lying on the floor after care. Resident 6 had severe cognitive impairment, renal insufficiency, neurogenic bladder, an indwelling urinary catheter, bowel incontinence, and a feeding tube while in the facility. During incontinence care for Resident 6, a QMA and a CNA entered the room, donned gloves, and removed a feces-soiled brief. The CNA cleaned feces from the resident’s backside and then, after rolling the resident onto her back, cleaned feces from the front perineal area. Using the same washcloth, the CNA then cleaned the indwelling catheter tubing without changing to a clean cloth between areas. The staff changed gloves only after completing this cleaning, then applied ointment and a clean brief. The staff did not don gowns despite a sign on the resident’s door indicating Enhanced Barrier Precautions (EBP) requiring gown and glove use for hygiene and device care. After care, the catheter drainage bag remained with six to eight inches lying on the floor by the wall. For Resident 6’s G-tube care, an LPN performed site care by washing hands, donning gloves, cleaning around the abdominal entry site with liquid-soaked gauze, and applying a split gauze dressing and tape. A moderate amount of dried blood was noted on the gauze pads used to clean the site. The LPN did not wear a gown while providing this device care, despite the posted EBP sign requiring gown and glove use for device care such as feeding tubes. In a separate incident involving Resident 7, an LPN preparing medications unlocked the medication cart and narcotic drawer, popped two pills directly into her bare hands, and then placed them into a medication cup before administering them to the resident. The Infection Preventionist later indicated staff should not touch resident medications with bare hands during medication administration.
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