Failure to Follow Catheter Care and Infection Control Protocols
Penalty
Summary
A deficiency was identified when a nursing assistant failed to provide proper urinary catheter care for a resident with severe cognitive impairment and an indwelling urinary catheter due to obstructive uropathy and an enlarged prostate. The resident's care plan required staff to use Enhanced Barrier Precautions, including wearing gloves and gowns during high-contact care activities, and to position the catheter bag appropriately, monitor for signs of infection, and use proper hand hygiene. During an observed care episode, the nursing assistant donned double gloves without using hand sanitizer, placed the resident's urine collection graduate directly on the floor without a barrier, and failed to perform hand hygiene after removing the top layer of gloves. The assistant stated that double gloving was a personal practice and acknowledged that it was not in line with facility expectations. The assistant also admitted to not using a disposable washcloth under the graduate, which was contrary to facility instructions to prevent the spread of infection. Interviews with nursing and administrative staff confirmed that facility policy required hand hygiene after glove removal and the use of a barrier between the floor and the graduate when draining catheter bags. The facility's policies on hand hygiene, indwelling urinary catheter care, and Enhanced Barrier Precautions all emphasized these practices to prevent contamination and infection. The observed failure to follow these protocols constituted a deficiency in providing appropriate catheter care and infection control.