Deficient Catheter Care and Infection Control Practices
Penalty
Summary
A resident with a history of benign prostatic hyperplasia and moderately impaired cognition was admitted with an indwelling Foley catheter following an episode of urinary retention and treatment for a urinary tract infection. The facility failed to ensure that the resident received appropriate care and treatment for the catheter, as observations revealed the catheter and associated equipment were not dated, and the catheter tubing was not attached to the securement device as required by facility policy. Staff interviews confirmed a lack of awareness regarding the absence of dating and improper securement, with staff attributing the missing date to the catheter being inserted at the hospital. Additionally, during catheter care, a CNA was observed improperly donning and doffing personal protective equipment (PPE), including putting on gloves before the gown, not changing gloves or performing hand hygiene after repositioning the resident, and removing gloves before the gown at the end of care. The CNA admitted to not following correct PPE procedures and identified the risk of cross-contamination. Facility policies required proper PPE use and securement of the catheter, but these were not followed, and relevant infection control policies were not provided upon request.