Failure to Provide Proper Catheter Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate care to residents with indwelling urinary catheters, resulting in multiple infection control breaches. For one resident with a neurogenic bladder and a history of urinary tract infections (UTIs), staff were observed emptying the drainage bag but not cleaning the catheter tubing as required. During catheter care, the drainage bag was seen resting on the floor and later placed on the resident's bed, both actions contrary to infection control protocols. Staff also used a soiled towel to drape the resident and placed dirty linens on a clean area of the bed. Additionally, the staff did not clean the top inch of the catheter tubing near the insertion site and touched clean surfaces with soiled gloves after providing perineal and catheter care. Another resident with an indwelling urinary catheter due to obstructive and reflux uropathy was observed with the drainage bag positioned above the bladder, causing urine to backflow into the bladder. The drainage bag was also seen resting on the floor and later placed on the bed during care. After catheter care, the drainage bag was again raised above the resident's body, resulting in visible backflow of urine. Both residents reported that staff did not regularly clean their catheter tubing, and one noted frequent hospitalizations for UTIs and regular antibiotic use. Review of care plans and physician orders confirmed that catheter care was to be performed every shift, and the drainage bag was to be kept below the level of the bladder. However, there was no documentation in the electronic medical records for either resident indicating that catheter care was performed as ordered. Facility policy required cleaning the catheter from the insertion site outward and maintaining the drainage bag off the floor and below the bladder, but these procedures were not followed during the observed care.