Deficient Catheter Care and Infection Prevention
Penalty
Summary
Facility staff failed to provide appropriate care for residents requiring the use of indwelling and external catheters, resulting in deficiencies related to catheter management and infection prevention. For one resident with multiple advanced stage pressure ulcers, atrial fibrillation, and obstructive uropathy, the physician's orders did not specify the size of the catheter or bulb, nor the rationale for the indwelling catheter. The care plan indicated the use of a 14 French, 5-10 mL bulb Foley catheter for pressure ulcer care, with interventions to change the catheter per order and monitor for infection. However, observations revealed that the catheter stat lock was coiled around the tubing on multiple occasions, and the tubing contained cloudy urine with sediment. These findings were reported to nursing staff, but no comments or concerns were voiced by facility leadership during the final interview. In another instance, staff failed to ensure that a catheter urine drainage bag was properly clamped, resulting in urine leakage. A resident with quadriplegia and a stage 3 pressure ulcer was observed in a public area with a trail of urine leading from his wheelchair, due to an unclamped drainage bag. Staff interviews confirmed that the valve should have been clamped after emptying the bag, and the resident reported that his CNA forgot to close the valve, causing the leak. Documentation indicated that the bag was subsequently clipped and repositioned, and the resident was monitored for safety. These deficiencies were identified through observations, staff and resident interviews, and clinical record reviews. The facility did not provide required care to prevent complications associated with catheter use for two residents in the survey sample, specifically failing to secure catheters appropriately and to prevent leakage from drainage bags.