Improper Placement of Drainage Bags
Penalty
Summary
The facility failed to ensure the secure placement of drainage bags for two residents, leading to potential risks of dislodgement and infection. Resident #7 was observed in the hallway with his drainage bag resting on his lap and at times placing it on the floor without a privacy bag. Despite staff performing 15-minute checks, the bag was not noticed on the floor, indicating a lapse in monitoring. The resident's medical records revealed a history of severe cognitive impairment and noncompliance with treatment regimens, which included allowing the drainage bag to drag on the floor. Resident #8 was similarly observed with his drainage bag and tubing positioned in a manner that increased the risk of dislodgement. The tubing was noted to be on the wheelchair's wheels, and the resident was seen moving around with the bag in close proximity to the wheels. The resident's medical records indicated mild cognitive impairment and a history of prostatic hyperplasia, with no toileting program in place. The care plan for Resident #8 included interventions to manage the drainage bag properly, but the resident sometimes allowed the bag to drag on the floor. Interviews with staff, including an LPN and the DON, acknowledged the risks associated with the improper placement of the drainage bags. Despite efforts to educate the residents about the risks, compliance was inconsistent. The facility's failure to secure the drainage bags properly and monitor the residents' behavior led to the deficiency, as evidenced by the observations and interviews conducted during the survey.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident #7: The drainage bag was properly placed on the frame of the bed by the Director of Nursing. Resident #7 did not suffer any adverse effects r/t the drainage bag being on the floor. Resident #8: Nursing staff to provide a bag when out of bed to mitigate risk of tubing getting caught in the wheelchair wheel spokes and so the resident does not place the drainage bag on his lap. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: Quality review by the DON/designee of current residents with an indwelling catheter to ensure drainage bags are secure and the drainage bag is not on the floor and the drainage bag is covered, to be completed by [date]. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Current licensed nurses are re-educated by the DON/designee on the components of this regulation and to ensure drainage bags are secure, the drainage bag is not on the floor and the drainage bag is covered to be completed by [date]. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: DON/designee to conduct ongoing quality monitoring through visual observation of residents with an indwelling catheter to ensure drainage bags are secure, the drainage bag is not on the floor and the drainage bag is covered 3 x weekly x 2 weeks, 2 x weekly x 2 weeks then weekly and PRN as indicated. The findings of these quality reviews will be reported to the Quality Assurance/Performance Improvement Committee monthly x 2 months or until substantial compliance is met then quarterly ongoing. Schedule to be modified PRN based on findings.