Failure to Follow Catheter Care Standards and Infection Control Practices
Penalty
Summary
The facility failed to adhere to professional standards and its own policies regarding the care and management of indwelling urinary catheters for two residents. For one resident, the facility did not initiate Enhanced Barrier Precautions (EBP) as required by its policy for residents with indwelling medical devices, delaying implementation for approximately seven weeks after catheter placement. Additionally, catheter care was not documented as performed every shift as ordered, and the catheter was not consistently secured with a holder to prevent migration, as required by physician orders and facility policy. For another resident, observations revealed that the urinary catheter was not secured to the thigh and was freely moving, with the securement device not attached or dated. Staff interviews confirmed that catheter securement was inconsistently performed, with CNAs indicating that reattachment was the responsibility of nurses and that they reported detachment to nursing staff. During care observations, a CNA failed to change gloves between tasks, using the same gloves to clean the resident, handle the catheter tubing, and touch various surfaces and items, which is inconsistent with infection control standards. The resident also reported that staff did not perform hand hygiene before providing urinary care. Record reviews showed that catheter care was not initiated in the care plan until several days after the physician's order for catheter placement, and EBP interventions were not included in the care plan. Documentation also indicated that catheter securement was not performed on specific shifts as required. One resident developed a urinary tract infection, for which antibiotic treatment was ordered. Staff interviews revealed inconsistent practices regarding the timing and performance of catheter care, as well as monitoring for signs of infection.