Failure to Maintain Proper Catheter Care and Prevent UTI
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter did not receive appropriate care to prevent urinary tract infections. During observation, the resident's catheter drainage bag and tubing were found resting on the floor, despite facility protocols requiring that these items be kept off the floor and below the level of the bladder. Staff interviews confirmed awareness that the catheter bag and tubing should not touch the ground to prevent infection, and that the drainage bag should be hung on the bed frame below the bladder. The facility's own Incontinent Care skills checklist also specifies that the drainage bag must be kept off the floor at all times. The resident involved was an 82-year-old female with a history of urinary tract infection, acute pyelonephritis, and hydronephrosis. She required substantial to total assistance with bed mobility, toileting, and personal hygiene, and had an indwelling urinary catheter as documented in her care plan. Despite these needs and the established protocols, the failure to maintain proper catheter care was observed and acknowledged by both nursing staff and facility administration. The facility did not have a specific Catheter Care/Maintenance policy and relied on the Incontinent Care skills checklist.