Deficient Infection Control Practices in Catheter Care
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's infection prevention and control practices related to the management of indwelling urinary catheters. For two residents, staff failed to properly secure urinary drainage bags, with one bag observed hanging from a trash can and another resting on the floor. These actions were contrary to both the residents' care plans and facility policy, which require catheter bags to be kept off the floor and positioned below the level of the bladder. Staff interviews revealed uncertainty about appropriate placement of catheter bags, and some staff admitted to using the trash can as a hanging point due to a lack of alternatives. In another instance, a staff member providing catheter care to a resident did not consistently follow proper hand hygiene protocols during glove changes and failed to don a gown as required by enhanced barrier precautions. The staff member also handled clean and dirty items without appropriate hand hygiene and did not use a dignity cover for the catheter bag. The resident's care plan and posted CDC guidance required the use of gloves and gowns for high-contact care activities, but these were not consistently followed during the observed care. All three residents involved had significant medical histories, including chronic kidney disease, neurogenic bladder, renal insufficiency, and a history of urinary tract infections. Their care plans specified interventions for catheter care, positioning, and infection prevention, but these were not adhered to during the survey observations. Staff and the Director of Nursing confirmed that the observed practices did not meet facility expectations or policy requirements.