Failure to Follow Infection Control Guidelines for PICC Lines and Urinary Catheters
Penalty
Summary
The facility failed to follow infection control guidelines for three residents with either a peripherally inserted central catheter (PICC) line or indwelling urinary catheters. One resident with a PICC line had a physician's order and facility policy requiring the dressing to be changed every seven days, but the dressing was not changed for at least 13 days after placement. The resident and an LPN confirmed that the dressing had not been changed since the initial placement, despite the policy and order. Two other residents with indwelling urinary catheters were repeatedly observed with their catheter drainage bags or tubing touching or resting on the floor, both while in bed and in a wheelchair. Staff interviews confirmed that catheter bags should not touch the floor, and one CNA noted that the dignity sleeves used were too large, causing the bags to slide out and touch the floor. Facility policy required appropriate catheter care and maintenance of dignity and privacy, but these standards were not met during multiple observations.