Deficient Catheter Care and Infection Control Practices
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, and an indwelling Foley catheter did not receive appropriate catheter care as required by facility policy and physician orders. During an observed catheter care procedure, a CNA failed to change gloves and perform hand hygiene after cleaning the resident’s buttocks and before handling clean linens and clothing. The same gloves were used throughout the process, and the CNA was uncertain about the correct protocol for glove changes and hand hygiene. Another CNA present did not intervene or clarify the procedure, despite recognizing the lapse. Additionally, the resident’s Foley catheter was not secured with a catheter securement device as required by the care plan and treatment orders. Both CNAs and the LVN confirmed that the securement device was missing and acknowledged its importance in preventing injury from catheter pulling. The absence of the securement device was not reported to the nurse, and the LVN was unaware of its omission until the surveyor’s observation. The resident’s Foley catheter drainage bag was also observed touching the floor after the bed was lowered by a CNA. Both CNAs and the LVN recognized that the drainage bag should not be on the floor, as per facility policy, but the issue was not corrected during care. Interviews with staff, including the DON and Administrator, confirmed expectations for proper catheter care, use of securement devices, and keeping drainage bags off the floor, but these standards were not met during the observed care for this resident.