Failure to Provide Proper Catheter Care and Adhere to Infection Control Protocols
Penalty
Summary
Facility staff failed to perform urinary indwelling catheter care in accordance with accepted standards of practice and the facility's own policy. Observations revealed that catheter tubing was not anchored to the resident's thigh as required, and staff did not follow proper hand hygiene protocols during catheter care. Specifically, a CNA continued to use a soiled washcloth and gloves after the resident had a bowel movement, only changing gloves without performing hand hygiene, and then resumed care. Additionally, the catheter tubing remained unsecured throughout the procedure, and the drainage bag was raised above the bladder during dressing, which is inconsistent with best practices. Record review for the resident involved showed a history of conditions including a right artificial hip joint, history of falls, and a need for assistance with personal care. The resident had an indwelling urinary catheter in place, with physician orders for catheter management and irrigation, but there was no specific order for routine catheter care or for securing the catheter tubing. The resident was also being treated for a urinary tract infection with antibiotics at the time of the observations. Interviews with staff indicated a lack of understanding and adherence to documentation and catheter care protocols. The LPN was unaware of the need for an order for catheter care and did not know if the catheter should be anchored. The CNA responsible for the care did not respond when asked about documentation practices. These actions and omissions contributed to the facility's failure to provide appropriate catheter care and to follow established infection prevention procedures.