Deficient Incontinence and Catheter Care Leading to Increased UTI Risk
Penalty
Summary
The facility failed to provide appropriate incontinence and catheter care for three residents, resulting in deficiencies related to the prevention of urinary tract infections (UTIs). For one male resident with a history of femur fracture, mild intellectual disability, and risk for skin breakdown, a CNA did not properly clean the resident's penis, scrotum, or pubic area during incontinence care. The CNA only wiped the anal area and groin, neglecting the necessary cleaning of the genital area, and did not perform hand hygiene after glove changes. Another male resident with Parkinson's disease, chronic kidney disease, and a current UTI was observed receiving inadequate catheter and perineal care. The CNA failed to change the surface of the peri-wipes when cleaning the genital area, did not clean the catheter tubing from the tip of the penis downward, and placed the urinary drainage bag on the bed, above the level of the bladder, during care. The CNA also did not perform hand hygiene between glove changes and applied barrier cream with contaminated gloves. A third male resident, dependent on staff for all toileting and transfers and with a Foley catheter, was transferred using a mechanical lift while the urinary drainage bag was placed on his lap and later on the bed, both times above the level of the bladder. During incontinence care and a bed bath, the drainage bag remained on the bed, and staff did not consistently perform hand hygiene between glove changes. Staff interviews confirmed knowledge of proper procedures but acknowledged lapses in practice during the observed care.