Failure to Provide Proper Catheter Care and Maintain Infection Control
Penalty
Summary
The facility failed to provide appropriate catheter care and maintain proper infection control practices for four out of five residents reviewed for catheters. Observations revealed that one resident's indwelling urinary drainage bag was placed on a hook on her nightstand, and she reported that staff only emptied the drainage bag and did not provide daily peri care or clean the catheter tubing as required. Staff interviews confirmed that peri care and catheter cleaning were inconsistently performed, with some staff indicating that the resident was responsible for her own care, despite her care plan indicating substantial assistance was needed. Another resident was observed with a catheter drainage bag lying on the floor, which staff acknowledged was against infection control protocols. Additional observations showed improper handling of catheter drainage bags during transfers and personal care, including placing the bag above the level of the bladder and on the resident's lap, leading to urine backflow in the tubing. Staff interviews confirmed awareness that the drainage bag should always be kept below the bladder to prevent backflow, but this practice was not consistently followed. Documentation for the residents involved showed significant medical histories, including multiple sclerosis, chronic kidney disease, Parkinson's disease, Alzheimer's disease, and neuromuscular dysfunction of the bladder. Care plans for these residents identified the risk of infection related to indwelling catheters and outlined the need for proper catheter care and infection control measures. The facility's own policy required daily catheter care, keeping drainage bags off the floor, and maintaining the bag below bladder level, but these procedures were not consistently implemented as observed and reported.