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F0690
D

Failure to Maintain Sterile Technique During Catheter Insertion

Denison, Texas Survey Completed on 12-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a nurse failed to follow sterile technique during the insertion of an indwelling urinary catheter for a male resident with a history of obstructive and reflux uropathy, diabetes, and recent orthopedic surgery. The nurse, after preparing supplies and donning personal protective equipment, was observed to be unsure of the procedure, did not use the protective drape, and failed to wash hands after removing dirty gloves before putting on sterile gloves. Additionally, the nurse did not connect the urine drainage bag to the sterile catheter tube prior to insertion, and the drainage bag was not pre-connected as required by standard procedure. The nurse admitted to not maintaining sterile technique and not following the facility's policy and procedure for catheter insertion. The Director of Nursing confirmed that the facility did not have written policies and procedures for catheter insertion and relied on a nursing manual for standards of care. Review of the manual indicated that several required sterile techniques were not followed during the procedure.

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