Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper catheter care for a resident with a history of frequent urinary tract infections. During a complaint investigation, it was observed that the urine collection bag was not kept below the level of the resident's bladder during care, which is contrary to the facility's policy. The catheter care policy, dated 1/01/2000, requires that the drainage bag be kept below the bladder to prevent urine backflow and potential infections. However, during an observation, the urine collection bag was placed at the level of the resident's bladder, leading to backflow of urine during care. The resident involved had a history of cerebral infarction and diabetes, with mild cognitive impairment, and was usually understood and able to understand. The resident's care plan indicated the need for catheter care every shift due to obstructive uropathy and frequent urinary tract infections. Despite these instructions, staff members, including two Certified Nursing Aides and a Licensed Practical Nurse, failed to maintain the correct position of the urine collection bag during care. Interviews with the staff revealed a lack of awareness regarding the proper positioning of the urine collection bag, which was confirmed by the facility's Assistant Director of Nursing and Director of Nursing.
Plan Of Correction
Plan of Correction: Approved February 2, 2025 The facility will continue to ensure that each resident receives adequate treatment and services for a foley catheter, specifically proper placement of urine collection bag below waist-level to prevent complication. Corrective action took place immediately following care to Resident #4, placing urinary collection bag below level of bladder. Resident was assessed and monitored for 5 consecutive days for adverse effects. None noted. The residents’ care plan was reviewed and in concert with the current needs and a medical records review was completed with no abnormal findings. The Certified Nursing Assistants (#1 and #2) and Licensed Practical Nurse (#1) was immediately counseled and re-educated regarding proper placement of urinary collection bags during and after care, patency of tubing, and drainage bag below level of bladder to maintain unobstructed urine flow and prevent backflow of urine into the bladder. Staff has been audited by the Clinical Instructor and successfully demonstrated understanding of procedures. No further concerns have been identified. The facility identified other areas that could potentially be affected by the deficient practice by: - All residents with foley catheters had the potential to be affected by the deficient practice. - The Clinical Instructor conducted resident audits on all those with catheters verifying proper placement. There were no further issues. Measures that will be put in place or systematic changes to ensure that the deficient practice will not recur: - The Clinical Instructor provided an educational program to all certified nursing assistants and licensed nursing staff on proper placement of urinary collection bags during and after care, patency of tubing, and drainage bag below level of bladder to maintain unobstructed urine flow and prevent backflow of urine into the bladder. - The Clinical Instructor/Designee will conduct weekly audits of 50% of the resident population who have Foley catheters to verify proper placement of drainage bags. Audits will continue until 100% compliance is attained for 8 consecutive weeks. Results of the above will be provided to the Quality Improvement Committee on an ongoing basis to monitor compliance. The Director of Nursing will be responsible for monitoring compliance and follow up as necessary. If 100% compliance is not found, the staff involved will be counseled. The Quality Improvement Committee may make further recommendations including, but not limited to, ongoing education, additional audits, and/or process changes. Corrective action will be completed by (MONTH) 6, 2025. The Director of Nursing is responsible for the implementation of this plan with the Facility Administrator having overall responsibility for the conduct of the plan.