Infection Control Lapse with Urinary Catheter
Penalty
Summary
The facility failed to adhere to acceptable infection control practices concerning the care and treatment of a resident with a urinary drainage catheter. During an observation, it was noted that the catheter drainage bag and tubing of a resident were lying on the floor without any covering. This was confirmed by a Licensed Practical Nurse (LPN) who acknowledged that the drainage bag and tubing should not be in contact with the floor or any unclean surface. The resident involved had an admission date of March 17, 2025, and was diagnosed with osteolysis, chronic obstructive pulmonary disease (COPD), and a urinary tract infection. The Nursing Home Administrator also confirmed that catheter bags should not be placed on the floor and should be covered, indicating a lapse in following the facility's infection control protocols.
Plan Of Correction
No residents were negatively impacted. When notified by the surveyor, the Director of Nursing provided a privacy bag to the resident with a Foley catheter and ensured it was off the floor. The Director of Nursing observed all other residents with Foley catheters to ensure they had privacy in place and that it was not touching the floor. The Regional Director of Clinical Operations educated the Administrator and Director of Nursing on the Catheter Care Policy and infection control policy on 4.15.25. The Director of Nursing/designee will educate all direct care staff on the Catheter Care policy and infection control policy beginning on 4.15.25. All education will be completed by 5.1.25. The Director of Nursing/designee will audit all residents with Foley catheters three times per week for four weeks to ensure that proper policy and infection control measures are being followed. Audits will begin on 5.1.25. Results of the audit will be reviewed by the QA committee to determine further need.