Failure to Maintain Catheter Bag Placement and Proper Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for two residents with indwelling urinary catheters, specifically by not ensuring that catheter drainage bags were kept off the floor and by not following proper incontinence care procedures. For one resident, observations showed that the catheter drainage bag was repeatedly seen touching the floor while the resident was in the dining room and in the wheelchair. During catheter and incontinence care, a CNA was observed using improper technique, including wiping from back to front and reusing the same area of a disposable wipe multiple times, both of which were acknowledged by the CNA as cross-contamination risks. The CNA admitted to having received recent in-service training on proper catheter and incontinence care, but did not follow the expected procedures during the observed care. Another resident was also observed multiple times with the catheter drainage bag dragging on the floor while in the wheelchair, including while self-propelling through the facility. Staff interviews confirmed that CNAs were responsible for ensuring catheter bags did not touch the floor, and staff acknowledged that failure to do so could result in cross-contamination and infection control issues. The facility's policies and procedures for perineal and catheter care explicitly stated that catheter bags and tubing should be kept off the floor and that clean techniques should be used during perineal care, including wiping from front to back and using a clean area of the wipe for each stroke. Both residents had care plans and physician orders that included specific instructions for catheter care, such as keeping the drainage bag off the floor, using privacy bags, and providing perineal care after each incontinent episode. Despite these documented interventions, staff did not consistently implement them, as evidenced by direct observations and staff interviews. The failure to adhere to established protocols and care plans resulted in deficiencies related to infection control and proper catheter and incontinence care for residents with indwelling urinary catheters.