The September 15 incident at Bishop Drumm Retirement Center involved a resident with muscular dystrophy who depends on staff for all daily activities and requires breathing, feeding, and urinary devices to survive. Federal inspectors documented how Staff A, a registered nurse, systematically violated infection control procedures during a complex wound care routine.
The resident, identified as Resident #15, has a tracheostomy tube for breathing, a gastric feeding tube for nutrition, and a suprapubic catheter for urination. The facility's own care plan required enhanced barrier precautions for any close contact with this resident due to infection risks from the catheter.
Staff A began the treatment properly, putting on a gown and gloves before entering the room at 2 PM. But what happened next violated every principle of infection control the nurse had been trained to follow.
The nurse removed an old dressing from an open wound on the resident's left buttock, cleaned the wound, and applied a new dressing with treatment paste. Without changing gloves or performing hand hygiene, Staff A moved to the resident's right buttock and repeated the process on a second wound.
Still wearing the same contaminated gloves, the nurse then removed the old dressing from the suprapubic catheter site on the resident's lower abdomen, cleaned the insertion site, and applied a new dressing. The cross-contamination continued as Staff A moved to the gastric feeding tube site, removing the old dressing and cleaning the area with the same gloves that had touched multiple wound sites.
The final violation came when the nurse removed the tracheostomy dressing and cleaned around the breathing tube opening in the resident's neck, still wearing gloves contaminated with drainage from four other sites.
Thirty minutes later, inspectors found Staff A sitting on the resident's bed, administering medication through the feeding tube without wearing any protective equipment at all.
The facility's own policies, revised the day after the inspection, explicitly require staff to change gloves "when going from dirty to clean when completing dressing changes." The enhanced barrier precautions policy specifically lists feeding tubes, tracheostomy tubes, urinary catheters, and wound care as high-contact activities requiring gown and glove use.
Even the facility's infection control preventionist violated protocols during the same visit. Inspectors observed her providing oral care to Resident #15 while wearing only gloves, with no gown despite the resident's enhanced precaution requirements.
The infection control preventionist later acknowledged witnessing Staff A's failures but took no immediate corrective action during the treatment. In an interview the following day, she confirmed that staff should change gloves and perform hand hygiene between different body sites during wound care.
She also stated her expectation that staff wear both gowns and gloves during high-contact care like feeding tube medication administration, contradicting what inspectors had observed Staff A doing just 24 hours earlier.
The resident affected by these violations represents one of the facility's most vulnerable patients. The quarterly assessment documented severe swallowing difficulties, malnutrition, and respiratory failure requiring mechanical support. The resident cannot eat, use the toilet, or transfer without complete staff assistance.
For someone dependent on multiple medical devices inserted into their body, proper infection control isn't just policy compliance. It's the difference between healing and life-threatening complications.
Cross-contamination between wound sites can introduce bacteria from one infected area to previously clean sites. When staff use contaminated gloves to handle feeding tubes or tracheostomies, they risk introducing pathogens directly into the digestive or respiratory systems.
The timing of the policy revisions raises questions about the facility's infection control oversight. Both the enhanced barrier precautions policy and hand hygiene policy were updated on September 16, the day after inspectors documented the violations and one day before the inspection concluded.
Bishop Drumm Retirement Center serves 114 residents in Johnston. The facility received a minimal harm citation for the infection control failures, indicating inspectors determined the violations had limited immediate impact but created potential for serious harm.
The resident with muscular dystrophy continues to require complex daily care involving multiple medical devices and wound treatments. Whether that care now includes the basic infection control measures that should have protected them from the start remains an open question.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Drumm Retirement Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
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