Failure to Change Indwelling Urinary Catheter and Bag During UTIs
Penalty
Summary
The facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter (IUC). The resident, who had chronic kidney disease, neuromuscular dysfunction of the bladder, and urinary retention, required maximum assistance for toileting and personal hygiene. Despite having standing orders and facility policy to change the IUC and catheter bag in cases of infection, obstruction, or when the closed system was compromised, there was no documentation that these changes were made when the resident developed symptoms of UTIs and was started on antibiotics on multiple occasions. Nursing progress notes and medication administration records showed that urine specimens were collected and antibiotics initiated for the resident during episodes of UTI symptoms, but the IUC and catheter bag were not changed as required. Interviews with nursing staff and the Director of Nursing confirmed that the process for changing the IUC was not followed, and there was no documentation of catheter or bag changes at the time of infection. This deficiency was identified through interview and record review, and was not in accordance with facility policy or CDC guidelines.