F0880

D

Failure to Follow Infection Control Practices During Incontinence Care, Medication Administration, and Catheterization

Westernport, Maryland Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow its own infection prevention and control practices, including hand hygiene, glove use, separation of clean and dirty items, safe medication administration, and safe catheterization technique. For a resident with type 2 diabetes, incontinence, a colostomy, and a history of recurrent UTIs, a GNA provided incontinence care without changing gloves between dirty and clean tasks and without maintaining separation between contaminated and clean surfaces. During a partial bed bath, the GNA touched the bedside table, resident’s blanket, dirty linen, closet handles, and clean linen with the same pair of gloves. The GNA handled clean towels, clean sheets, and the faucet with gloves that had already been used on dirty items, and used wet towels taken from the trash bin to clean the resident’s genital area, then placed used towels on clean surfaces, including a clean sheet next to the resident. After applying prescription zinc cream, the GNA touched the bedside table with contaminated gloves, then removed gloves and gown, discarded them, and exited the room without performing hand hygiene, later re-entering the room and donning gloves without prior handwashing to wash the resident’s face.

For another resident with spinal stenosis, bilateral lower-extremity weakness, vertigo, muscle weakness, neuropathy, and a bone disorder, an LPN failed to perform hand hygiene during medication administration. The LPN did not sanitize hands before entering the room or before donning gloves and administered 11 medications without performing hand hygiene between tasks. While preparing and administering insulin, the LPN’s right glove ripped, and the LPN continued the procedure with only the left hand gloved. Using a bare hand, the LPN wiped the injection site with alcohol and administered the insulin injection, then did not wash or sanitize hands after removing the remaining glove. These actions were inconsistent with the facility’s hand hygiene policy, which required handwashing or sanitizing before resident contact, before donning gloves, after glove removal, and after contact with potentially contaminated items.

For a resident with active progressive multiple sclerosis, paraplegia, a history of recurrent UTIs, neurogenic bladder, and complete urinary incontinence, the facility’s practices around straight catheterization raised infection control and procedural concerns. Documentation showed repeated catheterizations for urine samples and a resident report that fecal matter was seen on the tip of a catheter used for urine collection. In a grievance and related complaint, the resident reported that during a straight catheterization, an RN touched the wrong area and poked near the anus while trying to locate the urethral opening, inserted the catheter into the vagina despite the resident shouting that it was the wrong place, then inserted the catheter into the urinary tract, causing pain. The resident also reported that the RN pressed on the abdomen to obtain more urine despite the resident stating it hurt, and that the catheter came out and the procedure was ended. The resident, who was alert and oriented with a BIMS score of 15, consistently described these events to facility staff. The DON acknowledged that catheterization is a sterile procedure and that the expectation was to keep the procedure as clean and sterile as possible with clean gloves and careful technique, and also acknowledged awareness that the RN later returned to the resident’s room to retrieve the catheter from the trash, which was not consistent with the DON’s expectations for handling the procedure and related supplies.

Interviews with facility leadership and the infection preventionist confirmed that staff were expected to follow specific infection control practices that were not observed in these cases. The nurse manager stated that staff were expected to wipe front-to-back, change gloves between dirty and clean tasks, wash hands, and gather all supplies before starting care, and confirmed that the resident with a colostomy was on enhanced barrier precautions. The infection preventionist described prior in-services on perineal care, hand sanitizing, working from outer to inner areas, changing gloves after dirty care and between new briefs, and performing hand hygiene before and after glove use, as well as expectations for hand hygiene during medication passes. The DON stated that catheterization was a sterile procedure and that the facility expected clean gloves and careful technique. Despite these stated expectations and policies, the observed care and documented events for the three residents showed failures to adhere to infection prevention and control practices during incontinence care, medication administration, and catheterization.