Failure to Follow Standard and Ordered Catheter Care for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow standard practice and physician orders for urinary catheter care for two residents. One resident with severe cognitive impairment had a urinary catheter with stool present on it. A CNA was observed providing catheter care by wiping the catheter toward the urethra and then away from it, rather than from the insertion site outward as described by the DON as standard practice. The resident’s spouse reported that the resident had been sent to the hospital for a severe infection and alleged that staff were not changing gloves between care, which was causing infection. Health status notes documented multiple hospital admissions for this resident for UTI and sepsis on several prior dates. Another resident with intact cognition and a suprapubic catheter was observed in bed with the suprapubic catheter insertion site dirty and surrounded by dry blood extending almost four inches around the site. The physician’s orders for this resident directed staff to cleanse the suprapubic catheter insertion site daily and as needed with soap and water unless otherwise ordered. At the time of observation, the suprapubic catheter site was not clean as ordered, and the DON stated that the suprapubic catheter should have been kept clean to prevent potential infection.
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