Failure to Maintain Infection Control for Indwelling Urological Devices
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for residents with indwelling urological devices. For three residents with urostomies or indwelling urinary catheters, observations revealed that their drainage bags and tubing were in direct contact with the floor on multiple occasions. Specifically, one resident with a urostomy was observed twice with the drainage bag and tubing touching the floor, despite care plans and physician orders indicating the need for daily urostomy care and enhanced barrier precautions. Another resident with a suprapubic urinary catheter was seen in a wheelchair with the catheter bag contacting the floor during two separate observations, even though the care plan required catheter care every shift and enhanced barrier precautions. A third resident with an indwelling urinary catheter was observed in the dining room with the catheter bag directly on the floor, despite similar care plan interventions for infection prevention. Record reviews confirmed that all three residents had diagnoses requiring indwelling urological devices and were dependent on staff for various activities of daily living. Interviews with the Infection Prevention Nurse confirmed that staff were expected to keep catheter drainage bags and tubing off the floor to promote infection control. The repeated failure to prevent these devices from contacting the floor constituted a breach of established infection control measures as outlined in the residents' care plans and facility protocols.