Penalty

Fine: $90,845

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Unit Manager #2 failed to follow the facility's Handwashing/Hand Hygiene policy while providing suprapubic catheter care to Resident #83. During the procedure, after cleaning the catheter site and removing her gloves, Unit Manager #2 did not perform hand hygiene before donning a new pair of gloves to apply a dressing. This action was observed directly by surveyors, and the facility's policy specifically requires hand hygiene after glove removal and before donning clean gloves for aseptic tasks. Resident #83 had a suprapubic catheter with a slightly reddened area at the insertion site, which was being cleaned and dressed by Unit Manager #2. The failure to perform hand hygiene occurred after the initial cleaning and before the application of a new dressing. Both the Infection Preventionist and the Director of Nursing confirmed in interviews that the expected procedure was not followed, and Unit Manager #2 acknowledged the oversight during her interview.