Improper Foley Catheter Management and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and services for a resident with an indwelling Foley catheter, in accordance with its own urinary catheter care and enhanced barrier precautions policies. The resident had diagnoses including quadriplegia, chronic kidney disease, and depression, was cognitively intact, and had a documented history of urinary tract infections. The care plan and Kardex directed staff to monitor for signs and symptoms of urinary tract infection, position the drainage bag and tubing below the level of the bladder, provide Foley catheter care every shift, and monitor and document Foley output every shift. On multiple observations during one morning, the resident’s urinary drainage bag, containing approximately 1,000 milliliters of amber urine with a large amount of white mucus in the tubing, was seen lying directly on the floor under the bed. An LPN entered the room to administer medications and later to feed the resident breakfast, but did not correct the position of the drainage bag, which remained on the floor at 8:55 AM, 9:10 AM, 10:16 AM, and 11:26 AM. Staff interviewed acknowledged that the drainage bag should not have been on the floor and that it should have been emptied because it was full, particularly given the resident’s propensity for urinary tract infections. Later that morning, despite a sign on the resident’s door indicating the need for enhanced barrier precautions and the availability of supplies, a CNA entered the room wearing only gloves and no gown to empty the urinary drainage bag. The CNA picked the drainage bag up from the floor, placed a clean urinal directly on the floor without a barrier, opened the drainage spigot, and filled the urinal to the top. The CNA then placed the drainage bag with the spigot open back on the floor, emptied the urinal into the toilet, returned the urinal to the floor, and finished emptying the bag into the urinal. The CNA replaced the spigot into the bag holder without cleaning the spigot tip with alcohol and confirmed that 1,800 milliliters had been emptied. Facility nursing leadership and the infection preventionist stated that drainage bags should never be on the floor and that staff were expected to follow enhanced barrier precautions, including gown and glove use, when providing care to residents with Foley catheters.
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