Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections for a resident with an indwelling urinary catheter. The resident, who had a history of recurrent urinary tract infections and was on antibiotics and prophylactic methenamine, was observed receiving improper catheter care. During the care, a CNA used soapy water from a hand soap dispenser and did not follow the correct procedure for cleaning, wiping from back to front instead of front to back, which is against the facility's protocol. The Director of Nursing initially praised the CNA's performance, but later acknowledged that the care provided did not adhere to the facility's guidelines, placing the resident at risk for infection. The CNA had previously completed competency training and attended an in-service on perineal and catheter care, yet failed to apply the correct techniques during the observed care session.
Plan Of Correction
1: What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; A. Resident #107 has no complication with her. B. CNA staff BB and CNA staff CC was reeducated on F590 and care. 2: How you will identify other residents having potential to be affected by the same deficient practice and what corrective action will be taken; A. Complete Audit of resident with to ensure appropriate interventions are in place and any abnormal findings were corrected. B. Audit of CNA competency for care completed and any abnormal findings was corrected. 3: What measures will be put into place or what systematic changes you will make to ensure that the deficient practice does not recur: A. License staff was educated on care. B. Competency for care was completed for current CNADs and will be obtained for any new hires. C. Education on F690 will be completed for staff, upon new hire orientation and annually. 4: 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 place. The Director of Nursing/Designee will do random audits of care to ensure proper procedure/techniques is being utilized weekly for four weeks then monthly for one quarter. The Director of Nursing/Designee will submit a report of findings to the Quality Assessment, Assurance and Compliance Committee monthly for one quarter.