Failure to Implement Proper Infection Control for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), paraplegia, and an indwelling urinary catheter did not receive proper infection prevention and control measures. The resident's care plan required enhanced barrier precautions, including the use of gowns and gloves during direct care, and specified that the urinary catheter drainage bag should be kept below bladder level to prevent backflow. However, observations revealed that staff did not consistently use personal protective equipment (PPE) such as gloves and gowns when providing care, as reported by the resident herself. The resident expressed concern that this lack of PPE use was contributing to her recurrent UTIs. During direct care, certified nurse aides (CNAs) were observed removing the Foley catheter bag from its privacy bag and placing it on the bed above the resident's bladder level. This action caused urine from the external measuring device to flow back up the catheter tube into the resident's bladder. The CNAs admitted they were unfamiliar with the external measuring device and had not received training on its proper use or the importance of bag placement. Additionally, a soaker pad was found to be wet with urine, and the CNAs stated that the resident did not normally have catheter leakage. A review of the facility's catheter draining bag emptying policy revealed it lacked instructions on keeping the Foley bag below bladder level and on cleaning the emptying device tip with alcohol after use, both of which were included in the hospital's discharge instructions for the resident. The resident also reported that staff did not use alcohol swabs or paper towels when emptying the catheter bag, and that she was not checked or repositioned during the night as required by her care plan.