Failure to Enforce Pet Visitation Rules and Maintain Proper Catheter Bag Positioning
Penalty
Summary
The facility failed to establish, maintain, and implement an effective infection prevention and control program related to animal visitation and indwelling urinary catheter care. The facility’s Infection Control Policies and Practices required an organized, effective program to prevent, identify, control, and reduce the risk of infections, and the Animal Visitation Pet Policy limited visiting animals to certain species, required prior arrangements with the activity department, and mandated up-to-date vaccinations and veterinary checkups with documentation on file. The pet policy also prohibited animals from nurses’ stations and other areas requiring sanitary precautions, and required pets to be leashed or caged. Despite these policies, an LPN brought a sick chicken from her home into the facility without prior administrative approval, without veterinary evaluation, and without any documentation of vaccinations or preventive care. The LPN reported that she brought the sick chicken into the building at the start of her shift, kept it at the nurses’ station, and removed it from its carrier at the nurses’ station to clean the cage and to feed and hydrate the animal. She carried the chicken in her arms within the facility and allowed residents to pet it. The DON confirmed that the chicken was present for several hours, that he was aware the animal was sick, and that the LPN removed the chicken from its cage and allowed resident contact. These actions were not in compliance with the facility’s animal visitation policy and infection control protocols. CDC guidance cited in the report indicated that backyard poultry can carry multiple infectious agents and recommended that poultry and related equipment be kept outside and not permitted inside areas where people live or receive care. The facility also failed to follow its own policy for indwelling urinary catheter care for two residents with catheters. The Indwelling Urinary Catheter Care Procedure required that urinary drainage bags be positioned below the level of the bladder for gravity drainage but not placed directly on the floor, as improper handling or contamination of the drainage system increases the risk of urinary tract infection. Resident 1, who had dementia, severe cognitive impairment, urinary retention, and a suprapubic catheter, had a care plan that included maintaining a closed catheter system and providing full assistance with catheter care. During observation, this resident was in bed with the urinary collection bag resting directly on the floor, which was confirmed by the LPN present. Resident 2, who had obstructive and reflux uropathy, morbid obesity, moderate cognitive impairment, and an indwelling urinary catheter, also had a care plan specifying catheter care per routine and positioning the collection bag and tubing below the bladder with a privacy cover. During observation, this resident was seated in a wheelchair at the nurses’ station with the urinary collection bag resting directly on the floor, again confirmed by the LPN. The DON later confirmed that urinary collection bags should be maintained off the floor. These observations demonstrated that the facility did not adhere to its catheter care policy and did not maintain proper infection control practices for residents with indwelling urinary catheters.
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