Failure to Label Urinals and Secure Catheters Leads to Infection Control Deficiency
Penalty
Summary
The facility failed to provide appropriate care and services to residents who were incontinent of urine, specifically in the areas of urinal labeling and catheter care, as observed and documented by surveyors. Multiple residents, including those with significant medical needs such as respiratory failure, tracheostomy, ventilator dependence, neuromuscular dysfunction of the bladder, and severe cognitive impairment, were affected by these deficiencies. In several instances, urinals used by residents were not labeled with resident identifiers, despite facility policy and staff interviews confirming that labeling is required to prevent cross-contamination and infection. For example, in a shared restroom, an unlabeled urinal was found hanging from a mobility assistance bar, and staff acknowledged that this could result in urinals being used for the wrong resident. Additionally, a resident with an indwelling catheter was observed to have the catheter tubing unsecured, not anchored in the stat lock as required by physician order and facility policy. Staff interviews confirmed that the catheter should have been anchored to prevent accidental tugging or dislodgement, which could cause trauma and increase the risk of infection. The facility's policies on infection prevention, urinal use, and catheter care all specify the need for proper labeling and securement, but these procedures were not followed in the observed cases. Staff, including CNAs, RNs, the Infection Preventionist, and the Assistant Director of Nursing, all confirmed during interviews that the observed practices did not align with facility policy and could lead to cross-contamination and urinary tract infections. The documentation and interviews consistently indicated that the lack of urinal labeling and failure to secure catheter tubing represented a failure to implement established infection control measures for residents who are incontinent or require catheterization.