Failure to Provide Timely Incontinence Care and Proper Catheter Management
Penalty
Summary
The deficiency involves failure to provide timely incontinence care and appropriate catheter management for two residents. For one resident with extensive medical conditions including right-sided hemiplegia, Parkinson’s disease, cerebrovascular disease, chronic kidney disease, heart failure, and bowel and bladder incontinence, surveyors observed that when CNAs and a shift coordinator transferred him from a padded wheelchair to bed using a mechanical lift, the back of his pants, his buttocks, and his legs were soaked with urine. The pad and sling in his wheelchair were also wet, and staff verbally acknowledged that both the pad and sling were wet and needed replacement. The resident had a large reddened area on his right buttock. The DON stated that staff are expected to round on residents every two hours and provide toileting or incontinence care as close to every two hours as possible, and the resident’s care plan directed staff to provide incontinence care after each incontinent episode, consistent with the facility’s personal care policy requiring proper daily personal attention and care. The deficiency also includes improper catheter care and infection control practices for another resident with an indwelling urinary catheter and a history of UTI, acute cystitis, and colonization with ESBL in the urine. Surveyors observed this resident seated in a wheelchair in the dining room with the urinary drainage bag under the chair, uncovered by a dignity bag and touching the floor. A RN later moved the resident’s wheelchair without noticing that the drainage bag was dragging on the floor, and upon being informed, acknowledged that the bag should have a cover and should not be touching the floor for infection control reasons. The DON confirmed that catheter drainage bags should not touch the floor and that dignity bags are supposed to be used, with extras available. The resident’s care plan noted enhanced barrier precautions and a history of UTIs but did not include that she had an indwelling urinary catheter or any catheter-related interventions, and the facility’s catheter care policy did not address keeping drainage bags off the floor.
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