Deficiencies in Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper care for two residents with indwelling foley catheters, leading to potential risks of catheter dislodgement, pain, and infection. Resident #98, who was at risk for compromised skin integrity due to impaired mobility and incontinence, was observed without proper catheter securement, causing her pain. The resident had been in her wheelchair for five hours without being toileted, contrary to her care plan, which required toileting every two hours. Additionally, during incontinence care, the catheter was not secured to her leg, and no catheter care was performed, despite the resident's complaints of discomfort. Resident #65, who had a catheter due to bladder outlet obstruction, also did not receive appropriate care. The resident's catheter was not secured with a leg strap as required, and during incontinence care, the CNA did not change gloves after contact with feces, potentially leading to cross-contamination. The CNA also failed to apply barrier cream after cleaning the resident, which is part of standard incontinence care. These deficiencies were observed during staff interviews and direct observations, highlighting lapses in catheter care and infection control practices.
Plan Of Correction
Element #1: For resident #65 and #98, securement devices have been provided per the plan of care. Element #2: Residents residing in the facility receiving assistance with incontinence care and/or have foley catheters have the potential to be affected. Element #3: Licensed nurses and certified nurse assistants will be re-educated to ensure incontinence care and foley catheter care are consistent with professional standards of practice. Element #4: Under the direction of the Quality Assurance Performance Improvement (QAPI) Committee, Nurse Manager, or designee(s), will perform randomly weekly audits of dependent residents for appropriate foley catheter care and incontinence care. Weekly audits are to be submitted to the facility QAPI committee for review and further recommendations. Element #5: The Administrator is responsible for sustained compliance.