HOUSTON, TX - Federal inspectors declared immediate jeopardy conditions at Focused Care at Beechnut after discovering serious catheter care failures that caused a resident to develop a painful genital injury, according to a July 2024 inspection report.
Catheter Securement Failure Causes Genital Trauma
The most serious violation involved a 72-year-old male resident who developed a slit in his penis from the base to the scrotum due to an improperly secured urinary catheter. During the inspection, surveyors observed the resident's genital area was "red and raw" from the catheter trauma.
The resident told inspectors his catheter was "pulling and rubbing on his skin" and described it as "very painful." When asked about the facility's response time, he expressed concern about "why it took the facility so long to address his catheter."
Urinary catheters require proper securement to prevent movement that can cause tissue trauma. The tubing should be anchored to the patient's thigh with a specialized strap to eliminate tension on the urethral opening. When catheters are not properly secured, the constant pulling motion during patient movement can cause mechanical trauma to sensitive genital tissues.
The facility's care plan for this resident specifically included checking catheter tubing for kinks each shift and monitoring for signs of discomfort, yet staff failed to properly secure the device or recognize the developing injury in a timely manner.
Infection Control Protocol Violations
Federal inspectors also documented serious infection control failures during the same resident's personal care. Surveyors observed a certified nursing assistant providing catheter and incontinence care without following basic hygiene protocols.
The CNA failed to wash hands before putting on gloves and used the same contaminated gloves throughout the entire care procedure. After cleaning fecal matter from the resident, the aide continued using the same gloves to handle clean supplies and dress the resident without changing gloves or performing hand hygiene.
A medication aide who witnessed the care confirmed the infection control violations, stating the CNA "did not change gloves and she used the same gloves throughout the procedure."
Cross-contamination during personal care poses significant infection risks, particularly for residents with indwelling catheters who already face elevated urinary tract infection rates. The urethra and catheter insertion site are entry points for bacteria, making proper hand hygiene and glove changes essential infection prevention measures.
Immediate Jeopardy Declaration and Response
Federal regulations require immediate jeopardy status when a facility's practices create situations where residents face immediate risk of serious injury, harm, impairment, or death. The combination of catheter trauma and infection control failures met this threshold.
The facility implemented immediate corrective measures on June 28, 2024, including:
- Complete head-to-toe assessment of the affected resident - Pain assessment and physician notification - Updated care plan reflecting skin changes - Assessment of all residents with urinary catheters to ensure proper securement - One-on-one training for the treatment nurse on proper skin assessment and documentation
The facility also provided infection control training for all nursing staff, emphasizing proper catheter securement with thigh straps and requirements to report any trauma or irritation to supervisors and physicians.
Laundry Area Contamination Issues
Additional infection control violations were identified in the facility's laundry operations. Inspectors found personal items including food containers, eating utensils, and personal grooming items placed directly on tables used for folding clean linens.
Clean clothing and linens were stored on the floor in both clean and dirty areas of the laundry room. Staff acknowledged these practices violated infection control principles, with one employee stating that germs from personal items "could be transferred to the resident" through contaminated linens.
The hand-washing soap dispenser in the laundry's dirty section had been broken for at least two days, forcing staff to leave the area to wash hands in hallway restrooms. This practice created additional contamination risks as staff moved between different areas with potentially contaminated hands.
Medical Standards for Catheter Care
Proper indwelling catheter management requires specific protocols to prevent complications. The catheter drainage bag must remain below bladder level to prevent urine backflow, and the tubing should be secured to prevent tension on the urethral opening.
Daily catheter care includes cleaning the urethral opening and inspecting the insertion site for signs of irritation, infection, or trauma. Any changes in the catheter site or surrounding tissue require immediate assessment and potential physician notification.
Catheter-associated urinary tract infections represent one of the most common healthcare-associated infections. Proper securement and infection control measures are essential prevention strategies that directly impact patient safety and comfort.
Facility Response and Monitoring
Following the immediate jeopardy citation, Focused Care at Beechnut implemented enhanced monitoring systems including daily management rounds for all residents with urinary catheters. The facility also established improved communication protocols with specialty physicians to ensure timely follow-up care.
Federal inspectors confirmed the immediate jeopardy was removed on June 30, 2024, after verifying implementation of corrective measures. However, the facility remained cited for violations at a lower severity level pending evaluation of the long-term effectiveness of the implemented systems.
The inspection report documented extensive staff interviews confirming completion of required training on catheter care, pain assessment, and infection control protocols. Multiple staff members from different shifts received education on proper procedures for securing catheters and reporting changes in resident condition.
This incident highlights the critical importance of consistent implementation of basic nursing care protocols in long-term care facilities. Proper catheter management and infection control measures are fundamental safety practices that directly impact resident health and comfort.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Focused Care At Beechnut from 2024-07-02 including all violations, facility responses, and corrective action plans.
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