Infection Control Deficiencies Related to Foley Catheter Care and Personal Hygiene Product Storage
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents. For one resident with functional quadriplegia, a gastrostomy, and a tracheostomy, observations revealed that his Foley catheter tubing was resting on his fall mat and at times on the floor. Nursing staff, including LVNs and RNs, acknowledged that the tubing should not be on the floor or on the fall mat, as this does not follow infection control protocols. Staff interviews indicated that the resident's bed being in the lowest position made it difficult to keep the tubing off the floor, but it was still the staff's responsibility to ensure proper placement. Facility in-service records confirmed that staff had received training on Foley catheter care, including the importance of keeping tubing off the floor and allowing for gravity drainage. For another resident who was totally dependent on staff for activities of daily living and had diagnoses including diabetes, dementia, and a tracheostomy, two bottles of hair products labeled with other residents' names were found on her dresser. Staff interviews confirmed that personal hygiene products should be labeled and stored in a way that prevents cross-contamination, such as in sealed bags or drawers. The presence of these items in the resident's room was recognized by staff as a potential source of cross-contamination between residents' personal items. Facility policy reviews showed that there were established procedures for catheter care and infection control, including the prevention, identification, and control of infections. However, the observed practices did not align with these policies, as evidenced by the improper handling of catheter tubing and the storage of personal hygiene products belonging to other residents in a resident's room.