Failure to Provide Proper Catheter and Perineal Care Resulting in Repeated UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident had a history of overactive bladder, benign prostatic hyperplasia, and was always incontinent of bowels, requiring total assistance with lower body care. The care plan included monitoring for urinary complaints, pain, urine characteristics, and cognitive changes, with orders for monthly catheter changes and evaluation for signs and symptoms of UTI. Despite these interventions, the resident experienced multiple UTIs, as documented by positive urine cultures and symptoms such as hematuria and hallucinations. Direct observation of care revealed improper perineal and catheter care practices by staff. Nursing assistants used the same washcloth to clean areas contaminated with stool and then proceeded to clean the catheter area without changing cloths or gloves, and without performing hand hygiene between tasks. Staff also failed to change gloves or sanitize hands before applying barrier cream after handling the catheter and perineal area. These actions were inconsistent with infection control guidelines and increased the risk of introducing bacteria to the urinary tract. Interviews with the infection preventionist and director of nursing confirmed that there had been no surveillance or analysis of catheter-related infections, and no audits or education had been conducted to address proper catheter and perineal care. The facility's policy required clean technique when handling catheters, but this was not followed during observed care, contributing to repeated UTIs in the resident.