Deficient Catheter and Perineal Care Leading to Infection Risk
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide appropriate catheter and perineal care to a female resident with a suprapubic catheter and frequent bowel incontinence. During incontinence care, the CNA did not separate the labia or clean under the resident's skin folds, nor did she clean around the suprapubic catheter insertion site, despite visible leakage and redness. The resident was found with a strong urine odor, saturated brief, and a large bowel movement, but the required cleaning steps to prevent infection were not followed. Additionally, a registered nurse (RN) did not maintain sterile technique while re-inserting the resident's suprapubic catheter. The RN failed to set up a sterile field before donning sterile gloves, removed the sterile gloves after cleaning the stoma, and then continued the catheter insertion using utility gloves. The catheter was inserted and connected to the drainage bag, but urine was allowed to drain onto the resident's side, requiring further cleaning. The resident involved was cognitively intact, dependent on staff for toileting, and had diagnoses including multiple sclerosis and neurogenic bladder. Physician orders and care plans required regular catheter care and monitoring for infection, but the observed care did not adhere to facility policies for perineal and catheter care, as confirmed by staff interviews and policy review.