Improper Catheter Care and Infection Control Deficiency
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in managing the catheter and preventing urinary tract infections. The resident, who had a history of urinary tract infections and other urinary conditions, was observed with their foley catheter drainage bag improperly positioned above the level of the bladder, which is against the facility's policy. The drainage bag was also placed on the floor, and the tubing was kinked, both of which pose infection control risks. During multiple observations, staff members were seen placing the drainage bag in incorrect positions, such as on the wheelchair handle or armrest, and even directly on the floor. These actions were contrary to the facility's policy, which requires the drainage bag to be hung below the bladder level to ensure proper urine flow and prevent backflow, which can lead to infections. Interviews with staff, including certified nurse aides and registered nurses, confirmed that the drainage bag was not handled according to the established procedures. The facility's medical director and infection preventionist highlighted the increased risk of infection due to improper handling of the catheter drainage system. The staff's failure to adhere to proper catheter care protocols, such as ensuring the drainage bag was not touching the floor and was positioned correctly, contributed to the resident's risk of developing another urinary tract infection. The deficiency was identified through observations, interviews, and record reviews conducted during the standard survey.
Plan Of Correction
Plan of Correction: Approved February 13, 2025 What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 53 was evaluated by the medical provider and noted to be free from infection or signs of UTI. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents utilizing a foley catheter are at risk for the same deficient practice. A full house audit was completed on 2/10/25 to ensure all Foley drainage bags were kept below the residents’ bladder with tubing free of kinks and not placed on the floor. There was no further deficient practice noted. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? The facility’s policy titled Catheter Daily Care (Indwelling) was reviewed and no changes are necessary. All nursing staff will be re-educated by the Infection Preventionist on proper care and placement of foley bags and tubing to ensure residents who have an indwelling (Foley) catheter receive the appropriate care and services to manage catheters. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice? The Unit Managers will complete weekly observation audits x 4 weeks, then monthly x 2 months ensuring all foley drainage bags are properly placed below the bladder, that the drainage bag is properly secured before and after transfers, that there is no obstructed urine flow from improperly placed tubing, and that the drainage bag or tubing is not touching the floor. Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The Director of Nursing will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.