Failure to Implement and Maintain Effective Staff Training on Urinary Catheter Care and Infection Prevention
Penalty
Summary
The facility failed to implement and maintain an effective training program for nursing staff, specifically in the areas of urinary catheter care and infection prevention, following a facility-reported incident. Despite the facility's 5-day follow-up indicating that licensed staff would be educated on Foley catheter policies and procedures, interviews with staff and management revealed that no education had been provided prior to the survey. Educational materials were prepared and scheduled for future training, but staff, including those directly involved in the incident, confirmed they had not received any education or competency checks related to urinary catheter care. The Director of Nursing Services and the Educator both acknowledged that while resources were gathered, no directive was given to begin education, and the planned training had not been implemented. Additionally, the facility did not provide orientation or education on urinary catheter care and infection prevention to agency nursing staff, relying solely on competencies provided by the staffing agency. Review of agency staff records showed a lack of evidence for education on urinary catheter care. Interviews with agency LPNs confirmed they had not received any training from the facility on catheter care, transmission-based precautions, or enhanced barrier precautions. One LPN demonstrated a lack of understanding of enhanced barrier precautions, indicating gaps in knowledge and training among both facility and agency staff.