Failure to Maintain Proper Catheter Positioning and Hygiene
Penalty
Summary
The facility failed to follow its policy and procedures for catheter care by not ensuring that residents' catheters were positioned properly to prevent contamination. For one resident with a history of dementia, Parkinson's disease, traumatic brain injury, chronic kidney disease, urine retention, urinary tract infections, and other conditions, observations showed that the resident was sitting on his catheter tubing, with the tubing and bag placed directly on the floor and the catheter bag lacking a privacy cover. These observations were made on two separate occasions, and the resident's care plan required checking the tubing for kinks each shift. Another resident with a history of dementia, partial paralysis due to stroke, and urinary tract infection was observed in a wheelchair with his catheter tubing and bag dragging and rubbing directly across the floor, with part of the catheter bag exposed from the privacy bag. The resident reported recent groin pain related to the catheter, which resolved after adjustment. The facility's urinary catheter care policy requires that residents not lie on the catheter and that catheter tubing and drainage bags be kept off the floor, but these procedures were not followed for the two residents reviewed.