A resident with cognitive impairment, incontinence, and neurogenic bladder used a family-applied condom catheter at night for over a month without any physician orders, care plan interventions, or documented monitoring. Surveyors observed the drainage bag and tubing on the floor, with the condom catheter secured by duct tape. A CNA reported the family applied and removed the device and managed the drainage bag, while nursing staff, including LPNs and the DON, stated they were unaware of the device’s use and that no documentation, skin assessments, or monitoring of urinary output and characteristics had been completed.
Improper Urinary Catheter Bag Placement: Two residents with indwelling catheters had drainage bags and tubing observed resting on the floor, placed on the mattress, or raised above bladder level during care and transfers. The facility policy required the bag and tubing to stay off the floor and below the bladder, and staff interviews confirmed the bag should not be above the bladder or placed in bed with the resident.
Improper catheter care was observed for a resident with an indwelling urinary catheter, dementia, and hospice services. CNAs cleaned the catheter tubing with disposable wipes by wiping toward the insertion site, while multiple staff members, including an RN, Infection Control Nurse, and DON, stated the tubing should be cleaned away from the insertion site.
Catheter Care and Infection Prevention Deficiencies: The facility failed to provide proper catheter care for two residents with indwelling urinary catheters. One resident’s CNA emptied the drainage bag without wearing EBP, placed the measuring container directly on the floor without a barrier, and did not clean the drainage tubing afterward. Another resident’s catheter tubing was observed with a large dependent loop and positioned so it could touch the floor, contrary to the care plan and staff statements that tubing should remain free of obstructions and not contact the ground.
Two residents with indwelling catheters did not receive appropriate catheter management. One resident with a suprapubic catheter had the bag facing the door without privacy covering, sediment and discoloration in the tubing, and an infected abdominal fold with no gauze in place or physician order for a dressing. Another resident with a Foley catheter had no physician order for the catheter size, tubing changes, or urine output documentation, and urine remained in the tubing during observation while the resident reported a UTI and poor hygiene care.
Failure to follow physician orders for external catheter use. A resident with overactive bladder had orders for a PureWick only at bedtime, but observations showed it in place during the day while the resident sat in a recliner or lay in bed. CNAs said they applied it whenever the resident asked, and the DON stated staff did not notify the physician that the device was being used more often than ordered.
Incomplete catheter orders and failure to use EBP during catheter care were identified for a resident with an indwelling catheter. The resident, who was on hospice and had CKD, did not have a detailed catheter order in the chart or TAR, and staff observed emptying the catheter bag without gown and mask, with no EBP signage or PPE cart outside the room. Staff interviews confirmed the resident should have had detailed catheter orders, TAR documentation, and EBP precautions during direct care.
Failure to use EBP and provide proper catheter care: Two residents with indwelling urinary catheters were observed receiving direct care without the required gown-and-glove precautions, and one CNA continued care after touching a trashcan without changing gloves or performing hand hygiene. Staff also reused a disposable cleansing wipe on catheter tubing, and for another resident the catheter bag and tubing touched the floor during emptying. Interviews confirmed staff were unsure of the EBP and catheter-care requirements.
A resident with neuromuscular bladder dysfunction and an indwelling catheter did not have catheter care addressed in the care plan or physician orders, despite facility policy requiring catheter care every shift. During observed care, CNAs used a single washcloth on the inner thighs, did not change gloves or perform hand hygiene between perineal and bowel care tasks, failed to retract the foreskin, and cleansed the catheter tubing from the distal end toward the meatus instead of away from the body. Staff interviews, including with the CNA, another CNA, the DON, and the Administrator, confirmed that catheter tubing was expected to be cleansed away from the body to prevent infections, which was not followed in this instance.
A resident with urinary retention and an indwelling Foley catheter was observed sitting in a wheelchair with the drainage bag hanging from the chair, covered by a privacy cover, and about eight inches of tubing on the floor on multiple occasions. The resident said staff had not assisted with the catheter bag or tubing since around lunch time, and staff, the DON, and the Administrator all stated the bag and tubing should be kept off the floor and covered in a dignity bag.
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