The March 6 inspection at PruittHealth Franklin documented repeated failures by nursing staff to follow basic infection control protocols during catheter care and medication administration. Three residents were affected by staff who skipped hand hygiene steps or failed to wear required protective equipment.
The assistant, identified as CNA BB, was caring for a resident with a urinary catheter who required enhanced barrier precautions. She performed the initial hand hygiene but never put on a required gown. During the procedure, she emptied the full catheter drainage bag into a urinal, removed her gloves, then immediately donned new gloves without washing her hands.
Federal inspectors watched her clean around the catheter insertion site, wash the tubing downward toward the drainage bag, and change the resident's brief. Only after repositioning the resident for comfort did she sanitize her hands before leaving the room.
"She acknowledged the oversight, agreeing it was a fair observation, and admitted that she had failed to wear a gown for a resident on EBP and should have re-washed her hands after removing her gloves and before putting on a new pair during the procedure," inspectors wrote.
The facility's own policy requires staff to "perform hand hygiene and change gloves during resident care if moving from contaminated body site to a clean body site." For residents with indwelling medical devices like urinary catheters, enhanced barrier precautions mandate protective equipment during "high-contact care activities" including bathing, hygiene, changing briefs, and device care.
Licensed Practical Nurse CC made similar mistakes during medication administration. Inspectors watched her approach the medication cart at 8:40 a.m., log into her laptop, and begin preparing medications without sanitizing her hands. She entered the resident's room and administered the medications, again failing to sanitize upon entry. She only washed her hands when leaving.
"LPN CC admitted that she was nervous and had forgotten to do so," the report states.
A third incident involved LPN DD administering medications through a feeding tube to a resident on enhanced barrier precautions. The nurse properly donned a gown and performed hand hygiene upon entering the room. She confirmed tube placement, checked residual volume, and administered medications one by one with proper flushing.
But after completing the tube medications, she changed gloves without performing hand hygiene before putting on a new pair to apply topical ointment to the resident's leg. Only after changing gloves again did she wash her hands before administering insulin.
"When the surveyor questioned the nurse immediately after observing a medication pass about not sanitizing her hands after removing dirty gloves and before putting on a new pair to administer medication via a different route, she acknowledged that she should have performed hand hygiene at that time," inspectors noted.
The Director of Health Services confirmed during interviews that staff were expected to sanitize hands "immediately after removing gloves and before donning a new pair" and to follow facility policies when using protective equipment for high-contact care.
A separate violation involved a resident with cerebral palsy whose custom wheelchair sat unused in a closet while he remained bedridden. Physical therapy had discharged the resident in 2019 with specific instructions for daily use of his "personal custom tilt manual wheelchair" with hourly checks and regular tilting for pressure relief.
Inspectors found the wheelchair stored in the closet during three separate visits. The resident's care plan indicated he used a geri-chair when out of bed, but staff couldn't locate that either.
"R14 did not get out of bed, but there was no particular reason why at the moment," one licensed practical nurse told inspectors. "R14 got out of bed to get a shower and that was it."
A certified nursing assistant confirmed the resident "did not get up and get in his chair unless he was going to the doctor or the shower."
The unit manager said she had "never seen a wheelchair for him" and wasn't sure where the geri-chair was located. The administrator and director of nursing claimed they were unaware of the wheelchair and said the resident didn't have a tilt wheelchair, though they acknowledged he had one in the past when he was smaller.
Physical therapist KK explained that even after discharge from therapy, the positioning recommendations "were expected to be put in place indefinitely unless a licensed nurse deemed the recommendations to be inappropriate or the recommendations caused harm."
The resident's care plan, riddled with spelling errors, listed goals including participation in activities "of his liking" and remaining "free from injury." The approaches included keeping him out of bed in a geri-chair and providing activities in his room where he "likes to watch cartoons."
Instead, inspectors found him in bed during every observation, his custom mobility equipment gathering dust in storage.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pruitthealth - Franklin from 2025-03-06 including all violations, facility responses, and corrective action plans.
