Failure to Provide Proper Catheter Care Resulting in Infection
Penalty
Summary
The facility failed to follow its Indwelling Catheter Care policy for a resident diagnosed with Neuromuscular Dysfunction of the Bladder. The resident, who had moderate cognitive impairment, had a care plan indicating the need for catheter care to prevent trauma and promote cleanliness. Despite this, observations revealed that the resident's indwelling catheter drainage tube was covered with white particles and contained cloudy urine. The resident was unable to recall when the catheter was last changed, and staff interviews confirmed that catheter changes were only performed as needed, rather than on a regular schedule. The facility's policy required daily cleaning of the catheter insertion site, but the resident's catheter and surrounding area were found to be grossly soiled, with crust and foul-smelling liquid present. The resident was sent to the hospital with a fever and was found to have a grossly soiled indwelling catheter wrapped in the gluteal fold and around the leg, with purulent drainage and tenderness noted to the penis and lower abdomen. Hospital documentation confirmed the presence of a catheter-associated urinary tract infection, requiring antibiotic treatment. The hospital also noted minimal catheter output and significant post-void residual, indicating improper catheter function. These findings demonstrate that the facility did not provide appropriate catheter care or maintain cleanliness, resulting in a preventable infection and hospitalization.