Failure to Maintain Catheter Tubing and Bag Off the Floor
Penalty
Summary
The facility failed to ensure that a resident's urinary catheter tubing and privacy bag were kept off the floor, as required by facility policy. The policy, revised in September 2014, specifically stated that catheter tubing and drainage bags must not be placed on the floor. Resident #14, who had a history of epilepsy and severe cognitive impairment, was admitted to the facility in November 2012 and had an indwelling urinary catheter. The resident's care plan identified a risk for skin integrity issues related to the use of the catheter. Multiple observations revealed that the resident's catheter tubing and privacy bag were repeatedly found lying on the floor beside the bed. On several occasions, including when a CNA entered the room, the catheter bag remained on the floor and was not repositioned. During an interview, the Administrator confirmed that staff were trained and expected to maintain proper catheter care, but the required standard was not met in this instance.