Failure to Provide Proper Indwelling Catheter Care and Infection Control
Penalty
Summary
The deficiency involves failure to provide proper indwelling urinary catheter care for two residents, resulting in infection control concerns and a catheter-related hospitalization. One cognitively intact resident with multiple medical diagnoses, including urinary retention and obstructive/reflux uropathy, was observed in bed with an indwelling catheter whose drainage bag was approximately half full and placed directly on the floor. The resident stated he could not see what was on the floor and did not know the bag was there. An LPN confirmed during observation that catheter bags are not supposed to be on the floor, but should be hooked to the bed frame below the bladder to prevent germs from the dirty floor from entering the catheter and causing UTIs. The DON and another LPN separately stated that catheter bags should be hung on the side of the bed, away from the floor and below the kidneys, and that the catheter area is cleaned daily with normal saline and bags are positioned to allow downward urine flow and prevent backflow. The second resident had an indwelling Foley catheter and was care planned for risk of infection or complications related to catheter use due to neurogenic bladder. A nursing progress note documented that the resident was found lethargic, slow to respond, warm to touch, with abnormal vital signs including low oxygen saturation on room air and elevated temperature, and was sent to the hospital. Hospital records documented that the Foley catheter was reported as non-draining for an unknown period of time with a change in urine color to dark brown. On arrival to the ER, the resident had turbid urine, large leukocyte esterase, many bacteria, and was diagnosed with AMS, hypoxia on BiPAP, sepsis, hypotension, and UTI. The Foley catheter was found to be clogged and was changed, after which it drained freely, with urine described as dark brown. The resident’s catheter care order included changing the Foley catheter as needed for blockage, leaking, or malfunctioning.
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