Failure to Provide Proper Catheter Care and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to provide care in accordance with professional standards for a resident with an indwelling urinary catheter. Specifically, there was a discrepancy between the physician's order and the actual catheter inserted; the order specified a 16 French catheter with a 10 ml balloon, but the resident had a 16 French catheter with a 5 ml balloon. This mismatch was identified during a review of the resident's clinical record and confirmed by nursing staff. Additionally, the resident was not provided with a leg bag for urinary drainage when out of bed, despite facility policy and the resident's care plan indicating that a leg bag should be used to promote mobility, dignity, and privacy. Observations showed the resident in public areas with visible catheter tubing and drainage, and staff acknowledged that a leg bag should have been provided but was not. The facility also failed to implement Enhanced Barrier Precautions (EBP) during activities of daily living (ADL) care for the resident, who had a history of urinary tract infection and required a urinary catheter. There was no signage or personal protective equipment (PPE) available in the resident's care area, and staff performed care without donning appropriate PPE. Staff interviews revealed a lack of awareness regarding the resident's EBP status, and the infection preventionist confirmed that EBP had not been implemented as required.