Failure to Prevent UTIs in Resident with Indwelling Catheter
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. Resident 65, who was admitted with a urinary tract infection and benign prostatic hyperplasia, required the use of an indwelling catheter. The facility did not document the use of a leg bag for urinary drainage during daytime hours in the resident's care plan, despite it being part of the resident's routine care. This lack of documentation indicates a failure to individualize care to meet the resident's specific needs. Additionally, during an observation, the resident's urinary drainage bag was improperly stored inside a clear garbage bag tied to the railing beside the toilet, next to another resident's drainage bag, posing a risk for cross-contamination. The Director of Nursing confirmed that the urinary drainage bags were not being cleaned or stored according to infection control guidelines, and the facility could not provide evidence of staff education on the care and maintenance of urinary drainage systems. Furthermore, the facility lacked a policy or procedure outlining infection control practices specific to urinary catheters and drainage systems.
Plan Of Correction
Preparation and/or execution of this plan of correction in general, or this corrective action does not constitute an admission of agreement by this facility of the facts alleged or conclusion set forth in this statement of deficiencies. The plan of correction and specific corrective actions are prepared and/or executed in compliance with State and Federal laws. Prior deficiency cannot be corrected as the resident has expired. Establish a list of residents who have bedside urinary drainage bags and convert to leg bags during the daytime hours. Review the resident list to ensure their individual care plans are up-to-date. Revision of Intermittent Use of Urinary Leg Drainage Bags to include protocol for conversion to leg bag, aftercare, and storage of bedside urinary collection bags. Staff will be educated on the proper protocol for urinary leg bag conversion, emptying, cleaning, and storage of the bedside urinary drainage bag. Develop an audit tool to monitor the residents who utilize leg drainage bags to ensure their care plans are up-to-date, and audit proper disposal, cleaning, and placement of the bedside drainage bag daily. An audit of residents with indwelling Foley Catheter devices with leg bag conversions will be conducted daily, five x per week, x 3 months and results present to QAPI monthly x3.