Deficiencies in Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, as evidenced by deficiencies in catheter maintenance and infection control practices. For one resident with a suprapubic catheter, the facility did not document the required monthly catheter and bag changes in April, June, and November 2024, as ordered by the physician. This lack of documentation was confirmed by the Regional Nurse Consultant, indicating a failure to adhere to physician orders and facility policy regarding catheter care. Additionally, two other residents with foley catheters were observed with improper catheter management. One resident's urinary drainage bag was found lying on the floor without a cover, with the drainage valve touching the floor, which was confirmed by the Registered Nurse Assessment Coordinator (RNAC) as inappropriate. Another resident's foley catheter drainage bag was observed hanging off the wheelchair armrest, positioned higher than the bladder, which was also confirmed by the RNAC as incorrect placement. These observations highlight a failure to maintain unobstructed urine flow and proper infection control measures as per facility policy.
Plan Of Correction
1. Resident #1 suprapubic catheter was last changed on 10/11/2024. Physician was notified that suprapubic catheter was not changed as per order in April, June, and November. No ill effects occurred due to catheter not being changed. Resident #5 foley was immediately put in a basin so it didn't touch the floor. Resident #11 foley was repositioned to ensure it was positioned below the bladder. 2. Current residents with foley/suprapubic catheters were reviewed to ensure that catheters were being changed as per physician orders, that catheter bags were not on the floor, and to ensure that catheter bags were positioned below the bladder to prevent back flow of urine. 3. Director of Nursing or designee will provide education to Licensed staff and Certified Nurse Aides on Catheter care policy and the Supra pubic catheter policy. She will educate on following physician orders for catheter changes, ensuring that the catheter bags are not on the floor, and that the staff must position the catheter below the bladder to prevent back flow of urine. 4. The Director of Nursing or designee will audit to ensure that all catheters are changed per physician order, the foley is not on the floor, and that the catheter bag is positioned appropriately. Audits will be completed on all catheters 3x weekly for 2 weeks then monthly until compliance is met. Audits will be reviewed at quality assurance meetings monthly until compliance is met.