Catheter Drainage Bag Placed on Floor for Resident with UTI History
Penalty
Summary
A deficiency occurred when a resident with a history of recurrent urinary tract infections (UTIs), congestive heart failure, dementia, and neuromuscular dysfunction of the bladder was observed with her indwelling catheter drainage bag placed directly on the floor under her recliner. The resident required substantial to maximum assistance with toileting and had received diuretic medications during the observation period. The care plan specified that catheter care should be provided every shift and as needed, and the facility's policy required daily and as-needed catheter care to promote hygiene and decrease infection risk. Despite these requirements, the catheter drainage bag was found on the floor without a privacy bag, as observed during a morning check. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that catheter bags should never be placed on the floor and should be kept in a privacy bag below the bladder. The failure to follow these protocols resulted in a deficiency related to catheter care and infection prevention for the resident.