Inadequate Infection Control for Foley Catheter
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with an indwelling foley catheter. Resident #45, who had a history of urinary infections and dementia, was observed with a urinary drainage bag and catheter tubing that were improperly placed on the floor, which could introduce bacteria into the bladder. The spigot of the urinary collection bag was not secured and was also touching the floor. During an observation, a Certified Nurse Aide emptied the urine from the collection bag without sanitizing the spigot, and the foley catheter was not secured to the resident's thigh as required. The staff member admitted to not having alcohol pads and forgetting to clean the spigot, although they acknowledged the importance of doing so for infection control. Interviews with various staff members, including Licensed Practical Nurses and the Infection Preventionist, confirmed that the facility's protocol required the spigot to be cleaned with an alcohol swab after each use and that the catheter bag and tubing should not be on the floor. The staff also stated that the drainage bag should be dated and changed monthly or as needed. The Director of Nursing and other staff members reiterated the expectation that catheter drainage bags and tubing should be kept off the floor to prevent infection. The deficiency was identified as a failure to adhere to these infection control practices, as outlined in the facility's policy.
Plan Of Correction
Plan of Correction: Approved January 8, 2025 1. Resident #45 was assessed by RN for foley catheter care per policy and procedure including proper care of foley catheter care by staff. Any deficient findings were immediately addressed. All staff who provided care for Resident #45 was educated on policy and procedure for foley catheter care including proper infection control practices by RN Educator. All residents with foley catheters were audited by RN to ensure proper/appropriate practices were followed. Any deficient practices were corrected immediately. 2. All residents with foley catheter care are at risk for deficient practice of not following policy and procedure for proper foley catheter care including proper infection control practice. 3. Director of Nursing reviewed policy on foley catheter care and no changes were made to policy. 4. All nursing staff were trained by RN Educator on foley catheter care including proper infection control practices related to foley catheter care. 5. All residents with foley catheters will be audited weekly by unit manager/designee for month and monthly for 5 months for proper care of foley catheter care including proper infection control techniques. This will include staff competency to ensure they are following all practices per policy on foley catheters. Any deficient practices will be corrected and brought to QAPI for further review. Person Responsible: Director of Nursing