Infection Control Deficiencies in Urinary Catheter Care and Medication Room Sink
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two significant deficiencies observed during the recertification survey. The first deficiency involved Resident #17, who had severe cognitive impairment and an indwelling urinary catheter. Observations revealed that the resident's urinary drainage collection bag was lying directly on the floor without a barrier, contrary to the facility's policy that required catheter tubing and drainage bags to be kept off the floor. Interviews with staff, including a Certified Nurse Aide, a Licensed Practical Nurse, and a Registered Nurse Unit Manager, confirmed that the drainage bag should not touch the floor due to the risk of contamination and potential for urinary tract infections. The second deficiency was identified in the 2 South B side medication room, where the sink was found to be non-functional. The sink had a white substance on the handles, rust, and towels with a basin placed over them, preventing the water from being turned on. Staff interviews revealed that the issue had been reported to maintenance months prior, but the problem persisted, forcing staff to use alternative locations for handwashing. The Maintenance Director acknowledged the importance of having a functional sink for hand hygiene and was unaware of the ongoing issue in the medication room. These deficiencies highlight lapses in the facility's infection control practices, specifically regarding the proper storage of urinary drainage bags and the availability of functional handwashing facilities. The lack of adherence to established protocols and delayed maintenance responses contributed to the potential risk of infection for residents and staff.
Plan Of Correction
Plan of Correction: Approved February 10, 2025 The following corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: - Replace Resident #17 urinary catheter bag and place dignity bag over it, ensuring there is no contact with the ground when hung from the bed or wheelchair. - Clean and repair the sink in the medication room on 2 South. The facility will identify other residents having the potential to be affected by the same deficient practice and the following corrective action will be taken: - Audit all urinary catheter bags in the facility and educate Nursing Staff on infection prevention. - Audit all sinks in medication rooms to be sanitary and in working order. Educate maintenance department on timely work order responses. The following measures will be put in place and/or systemic changes will be made to ensure that the deficient practice does not recur: - Education on infection prevention (specifically catheters) to Nursing Staff. The corrective action(s) will be monitored to ensure the deficient practice will not recur: - Auditing urinary catheter bags throughout the facility x5/week times 3 months at 100%. - Auditing work order system repair timeliness and effectiveness x 5/week at 3 month 100%. The date for correction and the title of the person responsible for correction of each deficiency: - Date of Correction: 3/5/2025 - Person Responsible: Infection Preventionist.