Failure to Maintain Closed Foley Catheter System During Incontinent Care
Penalty
Summary
A deficiency occurred when a resident with an indwelling Foley catheter did not receive appropriate care to maintain a closed catheter system and prevent infection. During perineal and incontinent care, two nursing assistants assisted the resident in turning without first moving the Foley drainage bag, which was still attached to the bed rail on the opposite side. This action caused the catheter tubing to stretch tightly and ultimately disconnect from the drainage bag, with the tubing falling onto the resident's bed and coming into contact with a gloved hand. Following the disconnection, a nurse attempted to reconnect the same drainage bag and tubing to the resident's indwelling Foley catheter, despite the tubing having touched the bed and a staff member's glove. The nurse was unaware of this contact until informed by the surveyor and stated that she would have replaced the bag and tubing had she known. The nurse and both nursing assistants confirmed they had been trained in catheter care but did not follow proper protocol in this instance. The resident involved was a cognitively intact female with a flaccid neuropathic bladder, muscle weakness, and mobility issues, who was dependent on staff for perineal hygiene. Her care plan specified maintaining a closed catheter system and minimizing manipulation of the tubing. The facility's guidance, referencing CDC and AHRQ recommendations, required replacement of catheters and urine collection bags if the system became disconnected, which was not initially followed in this event.