Improper Catheter Care and Infection Control
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received essential care, as evidenced by multiple observations of the catheter drainage bag being improperly handled. The facility's policy on catheter care mandates that drainage bags should be covered and kept off the floor to maintain dignity and prevent infection. However, during observations on three separate occasions, the catheter drainage bag of a resident was found lying uncovered on the floor beside the bed. The resident indicated that the staff would be responsible for emptying the catheter bag, suggesting a lack of adherence to the facility's policy by the staff. The resident involved, identified as having multiple medical conditions including osteomyelitis, paraplegia, and protein-calorie malnutrition, was admitted to the facility in 2020. Interviews with a Licensed Practical Nurse and the Nursing Home Administrator confirmed the improper handling of the catheter drainage bag, acknowledging that it should be covered and maintained off the floor to prevent infection and ensure the resident's dignity. These findings highlight a deficiency in the facility's infection prevention and control practices as outlined in their policy.
Plan Of Correction
Resident #14 bag was removed from the floor at the time of findings. Residents were reviewed to ensure foley catheter bags were properly placed and covered. Nursing staff will be educated on catheter care policy and the need to ensure foley bag and tubing is not touching the floor by the Director of Nursing/Designee. Audit will be conducted 3 times a week for 4 weeks to ensure that foley bags are not on the ground and covered for all residents with foleys, then weekly for 4 weeks, then monthly ongoing by Director of Nursing/designee. Foley bags have built-in covers. Findings will be reported to the Quality Assurance Performance Improvement committee for review and recommendations.