Deficient Catheter Care and Infection Control Practices
Penalty
Summary
Two residents with indwelling urinary catheters did not receive appropriate care and services to prevent urinary tract infections, as evidenced by direct observations and staff interviews. One resident was observed multiple times with a catheter bag dragging on or resting in contact with the floor while being transported in a wheelchair and during wound care. Multiple staff members, including an LPN, the Nursing Home Administrator, and the Director of Nursing, acknowledged that catheter bags should not be in contact with the floor, in accordance with facility policy. Another resident received catheter and peri care from a CNA who failed to maintain proper infection control practices. The CNA placed soiled washcloths in the same garbage bags as clean washcloths, only separating them by keeping dirty ones in one corner and clean ones in another. The CNA also failed to perform hand hygiene between removing soiled gloves and donning new gloves during the care process, despite facility policy requiring hand hygiene at these points. The CNA later acknowledged that hand hygiene should have been performed and that mixing clean and soiled washcloths could be a risk for cross-contamination. Facility policies reviewed by the surveyor required catheter care every shift, proper hand hygiene before and after glove use, and separation of clean and soiled items to prevent infection. The Director of Nursing confirmed that hand hygiene should be performed after doffing and before donning gloves, and that clean and dirty washcloths should be kept in separate bags. These lapses in infection control and catheter care were observed and confirmed through staff interviews and record review.