Failure to Maintain Proper Catheter Tubing Placement
Penalty
Summary
Surveyors observed that the facility failed to implement proper infection control practices for a resident with an indwelling urinary catheter. Over multiple days, the resident was seen in both bed and recliner with the urinary catheter tubing and drainage bag resting on the floor. These observations were made on several occasions, indicating a repeated failure to maintain catheter tubing and drainage bag placement according to infection control standards. The resident involved had diagnoses including diabetes mellitus, cerebral infarction, and neurogenic bladder, and had a physician's order for monthly catheter changes. The resident's care plan addressed urinary retention but did not include instructions for proper placement of the catheter tubing while in bed or recliner. During an interview, a CNA acknowledged that the catheter tubing was sometimes on the floor and confirmed that it should not be. The facility's catheter management policy specified that collecting bags should always be kept below the level of the bladder and not resting on the floor, but this policy was not followed in practice.