Improper Placement of Indwelling Catheter Bag Resulting in Infection Control Deficiency
Penalty
Summary
The facility failed to ensure proper handling and placement of an indwelling urinary catheter for a resident with a history of chronic kidney disease, urinary retention, and recent urinary tract infections. The resident had a urinary catheter inserted as ordered, and during observation, the catheter bag was found hanging on a trash can containing trash and was touching the floor without any barrier to prevent contamination. This placement was in direct violation of the facility's catheter care policy, which requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Interviews with multiple staff members, including LPNs and CNAs, confirmed that they were aware catheter bags should not be hung on dirty surfaces or allowed to touch the floor, as this could lead to infection. The Director of Nursing also acknowledged that proper placement of the catheter bag is necessary to reduce infection risk. The resident involved was cognitively intact, independent with toileting, and had a recent history of urinary tract infections, further emphasizing the importance of proper infection control practices.