Failure to Provide Proper Catheter Care and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter, a history of flaccid neuropathic bladder, recurrent urinary tract infections, urine retention, and dementia, did not receive catheter care in accordance with physician orders and facility policy. Observations revealed that the resident's catheter drainage bag was stored in a privacy bag that was visibly soiled with a dried white stain and was seen dragging on the floor. The same soiled privacy bag was used on both the resident's wheelchair and bed. During catheter care, a CNA provided perineal care using only water, without soap, and did not clean the catheter tubing as required. The CNA also placed a clean incontinence brief on the resident while still wearing the same soiled gloves used during perineal care. Interviews with facility staff confirmed that catheter care should include cleaning the catheter tubing with soap and water, and that soiled privacy bags should be changed to prevent contamination. Facility policy and the resident's care plan both specify that catheter tubing and drainage bags must be kept off the floor and that careful perineal care should be performed to keep the catheter free from crusting. Despite these requirements, the observed practices did not align with the established protocols, resulting in a failure to provide appropriate catheter care to prevent urinary tract infections.