Failure to Maintain Sanitary Conditions for Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure that indwelling urinary catheters were maintained in a sanitary manner for two residents, R41 and R119, who were reviewed for catheter care. The facility's Urinary Catheter Care policy, dated September 2005, specifies that catheter tubing and drainage bags should be kept off the floor to prevent urinary tract infections. However, observations revealed that R41's catheter bag was hanging from his wheelchair without a protective dignity bag, with the tubing dragging on the floor. Similarly, R119 was found in bed with the catheter drainage bag and tubing resting on the floor, also without a protective dignity bag. Both residents had physician orders for the use of a 16 FR/10cc balloon indwelling urinary catheter due to urinary retention. Their care plans included goals to manage catheter care appropriately to prevent infections and reduce the spread of infectious agents. The care plans also emphasized the importance of not allowing the catheter tubing or drainage system to touch the floor and following the facility's infection control policies. Despite these documented interventions, the facility did not adhere to its own procedures, as confirmed by the Administrator and Director of Nursing.