Failure to Provide Proper Catheter Care and Prevent UTI
Penalty
Summary
A resident with a history of cancer, cerebrovascular accident, metabolic encephalopathy, and anxiety, who was severely cognitively impaired, was readmitted to the facility with an indwelling Foley catheter. The physician's orders specified monthly catheter changes, catheter care and drainage bag emptying every shift, and monitoring for complications, with instructions to ensure the catheter strap was in place and holding. However, the resident's comprehensive care plan did not include any plan for indwelling Foley catheter care. During observation, the resident was found lying in bed with the Foley catheter drainage bag placed on the floor and the catheter tubing inadequately secured to her leg, as the catheter strap had come off and was draped over the catheter. Nursing staff confirmed that the drainage bag should not be on the floor and the tubing should be properly secured, acknowledging that failure to do so could lead to cross-contamination and infection. Facility policy also required that catheter tubing and drainage bags be kept off the floor and properly secured, but these procedures were not followed in this instance.