Deficient Incontinent and Catheter Care Leading to Infection Control Lapses
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide proper incontinent and catheter care for two residents, resulting in deficiencies related to infection prevention and appropriate hygiene. For one resident with an indwelling Foley catheter and multiple complex medical diagnoses, including osteomyelitis, pressure ulcer, and functional quadriplegia, a CNA did not perform hand hygiene before care, did not open the labia to clean the catheter insertion site, and inadequately cleaned the resident after a large bowel movement. The CNA acknowledged not following proper technique and recognized that this could contribute to urinary tract infections (UTIs). Another resident with a history of cerebral infarction, hemiplegia, and other chronic conditions also received improper incontinent care. During care, the CNA did not open the labia to clean the perineal area, despite the presence of a strong urine odor. The CNA later admitted she should have opened the labia more thoroughly and had received prior training on the correct procedure. Facility policy requires specific steps for catheter and perineal care, including cleaning from the insertion site outward and performing hand hygiene before and after resident care. Interviews with staff and review of training records confirmed that initial and ongoing training was provided, but the observed care did not meet facility standards or policy requirements. These lapses in care were directly observed by surveyors and confirmed through staff interviews.