Failure to Perform Proper Catheter and Incontinence Care Increases Infection Risk
Penalty
Summary
A deficiency was identified when staff failed to perform catheter care according to appropriate standards of practice, increasing the risk of contamination and urinary tract infection. Review of a resident's medical record showed the individual had multiple diagnoses, including neuromuscular dysfunction of the bladder, and required an indwelling Foley catheter with care every shift. The care plan specified the need for enhanced barrier precautions and outlined that incontinence care should be provided prior to catheter care if the resident was soiled, to prevent contamination. During direct observation, a CNA did not check for bowel incontinence before starting catheter care and used washcloths that were placed directly on an unclean overbed table without a barrier. The CNA did not use a method to ensure a clean part of the washcloth was used for each stroke, did not use soap, and failed to clean the area around the catheter insertion site or the catheter itself. After incomplete catheter care, the CNA left and re-entered the room, changed only one glove without performing hand hygiene, and then performed incontinence care. The same soiled gloves were used to reposition the catheter tubing and fasten a clean brief, further increasing the risk of contamination. Interviews with staff confirmed that the observed practices did not align with facility policy or standard infection control procedures. Policies required the use of clean basins and washcloths, cleaning from the meatus outward with a clean part of the cloth for each stroke, and performing hand hygiene between glove changes. The failure to follow these procedures was corroborated by staff interviews and review of facility policies, which emphasized the importance of proper hand hygiene and cleaning techniques to prevent infection.