Failure to Provide Infection Prevention Support for Visually Impaired Resident Performing Catheter Self-Care
Penalty
Summary
Facility staff failed to ensure that a visually impaired resident received appropriate training and assistance with infection prevention measures during self-care of a urinary catheter. The resident, who had a history of neuromuscular bladder dysfunction, diabetes, and visual impairment, was assessed as cognitively intact but required varying levels of assistance with activities of daily living, including being dependent for toileting hygiene and requiring partial to maximal assistance with personal hygiene. Despite these needs, the resident reported performing his own catheter care, and staff interviews confirmed that CNAs were not instructed to assist the resident with this task beyond emptying the catheter. Observation of the resident's catheter care revealed improper technique, including the use of a single basin for both washing and rinsing, and reusing washcloths, which does not align with the facility's policy for urinary catheter care. The CNA assisting the resident acknowledged the error, stating that two basins should have been used—one for soapy water and one for rinsing. The CNA also indicated she had not been informed to assist the resident with catheter care aside from emptying the Foley catheter. Further interviews with nursing staff and facility leadership confirmed a lack of clear guidance and training for staff regarding their role in assisting the resident with catheter care. The facility's policy required specific steps for catheter care, including the use of separate washcloths and basins, but these procedures were not followed during the observed care. The resident's medical record indicated a history of urinary tract infections, underscoring the importance of proper infection prevention practices.