Failure to Maintain Infection Control for Urinary Drainage System
Penalty
Summary
The facility failed to ensure proper infection control practices for a resident with an indwelling urinary catheter. The resident, who had diagnoses including urinary retention, hydronephrosis, and a flaccid neuropathic bladder, required supervision with most activities of daily living and had a physician's order for a catheter but not for a leg bag. Observations revealed that the tip of the resident's urinary drainage tubing was repeatedly found lying uncapped on the bathroom floor, and the overnight urinary drainage bag was not maintained according to facility policy. The care plan and Kardex did not address the use or cleaning of the leg bag or overnight drainage bag, nor did they specify techniques to minimize infection risk. Staff interviews and observations showed that the overnight urinary drainage bag was cleaned daily using a solution of tap water and vinegar, which was injected into the bag with a catheter-tip syringe. The bag, along with the tubing, was then placed in a basin on the bathroom floor, and the tubing was often left uncapped and in contact with unclean surfaces. The cleaning supplies, including a jug of vinegar and a urinal, were stored together in the same basin as the drainage bag, contrary to policy. The graduate used for cleaning was not changed weekly as required, and the practice of using tap water and vinegar was not known to the infection preventionist. Facility policy required that catheter tubing should never touch the floor, that contaminated closed collection systems be replaced immediately, and that cleaning of drainage bags be performed with specific solutions and techniques, including proper drying and capping of tubing. These procedures were not followed, and the facility's documentation did not reflect the actual practices observed. The DON acknowledged the potential for infection due to these lapses and confirmed that the observed practices did not align with facility policy.