The improper technique violated the facility's own infection control policies and contributed to a urinary tract infection that sent Resident #15 to the emergency room with blood in their urine.
Federal inspectors observed the violation during a September 15 visit to Bishop Drumm Retirement Center. Staff A, a registered nurse, completed wound treatments on the resident before proceeding directly to catheter care without changing gloves or following proper cleaning protocols.
The resident lives with muscular dystrophy, respiratory failure, and requires a tracheostomy tube to breathe. They depend entirely on staff for eating, bathroom care, and moving between locations. A suprapubic catheter drains urine through a tube inserted into their lower abdomen.
During the observed catheter care, the nurse removed the old dressing, applied wound cleanser to a gauze pad, and wiped around the insertion site four times. Each wipe covered the same areas with the same contaminated section of gauze.
The nurse then applied a new dressing while still wearing the same gloves used for wound treatments.
One month earlier, another nurse had summoned help at 6:09 AM after discovering blood in the resident's urine and catheter tubing. Large sediment had accumulated in the tubing. The resident was transferred to the hospital emergency room that morning.
Hospital lab results revealed the scope of the infection. A urine culture completed August 16 and finalized three days later showed Enterococcus bacteria at levels exceeding 100,000 colony-forming units. The resident required antibiotic treatment.
The facility's own suprapubic catheter policy, approved the same day as the inspection, requires staff to wash and dry hands, apply gloves, and clean the insertion site using circular motions working outward from the catheter. The policy specifies using only one cotton ball or applicator for each cleaning stroke.
The facility's Infection Control Preventionist explained the proper technique during a September 16 interview. Staff should remove the old dressing, complete hand hygiene, apply new gloves, and cleanse around the catheter working from the insertion site outward.
"Not wiping over the same area again," the preventionist emphasized.
The contaminated glove technique observed by inspectors violated both requirements. The nurse failed to change gloves between procedures and repeatedly wiped contaminated areas with the same gauze section.
Suprapubic catheters require meticulous care because the abdominal insertion site provides a direct pathway for bacteria to enter the urinary system. Improper cleaning can introduce pathogens that cause serious infections.
The resident's medical history shows the vulnerability that made proper catheter care essential. Their muscular dystrophy has progressed to require breathing assistance through a tracheostomy. Malnutrition and difficulty swallowing compound their medical complexity.
With mild cognitive impairment, the resident depends on nursing staff to recognize symptoms and provide appropriate care. The August morning discovery of bloody urine represented a medical emergency requiring immediate hospital intervention.
The Enterococcus infection found in the resident's urine is particularly concerning. This bacteria commonly spreads through contaminated hands and medical equipment in healthcare settings. The same organism frequently causes healthcare-associated infections when proper hygiene protocols are not followed.
Hospital records show the resident returned to Bishop Drumm after emergency treatment, with orders for continued antibiotic therapy. The infection required ongoing medical management beyond the initial hospital visit.
The inspection occurred at a 114-bed facility where three residents with suprapubic catheters received care. Inspectors found catheter care violations affecting one of those three residents.
Federal regulators classified the violation as causing minimal harm with potential for actual harm. The contaminated glove technique and improper cleaning method created infection risks that materialized in the resident's documented urinary tract infection and emergency hospitalization.
The resident continues to require complex medical care including tracheostomy maintenance, nutritional support, and catheter management. Their muscular dystrophy will likely progress, making infection prevention increasingly critical to their survival and quality of life.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bishop Drumm Retirement Center from 2025-09-17 including all violations, facility responses, and corrective action plans.
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