Improper Catheter Care and Infection Control Lapse
Penalty
Summary
A deficiency occurred when a nursing assistant (NA) failed to provide proper catheter care to a resident with an indwelling Foley catheter. The resident, who had moderate cognitive impairment and multiple diagnoses including neurogenic bladder, multiple sclerosis, and dementia, required assistance with all activities of daily living. During evening care, the NA cleaned the catheter tubing in the wrong direction, wiping from the tubing up toward the urethral opening, and used the same rag to clean both bowel movement residue and the catheter. Additionally, the NA did not sanitize the ends of the catheter tubing or the overnight collection bag before connecting them. Interviews with the NA, infection preventionist, and DON confirmed that the catheter care provided did not follow facility policy or standard infection control practices. The facility's policy required cleaning from the urethral opening down the tubing, using separate rags for cleaning BM and catheter care, and sanitizing connections with alcohol before attaching a new collection bag. The observed actions were identified as improper and posed a potential risk for urinary tract infection.