Failure to Maintain Proper Catheter Bag Placement
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided adequate catheter care according to facility policy and current standards of care. The facility's policy, last reviewed on June 2, 2025, specifically stated that catheter bags should not be placed on the floor. Despite this, observations on multiple occasions showed the resident's catheter bag containing urine resting on the floor, and at one point, the overbed tray table wheels were on top of the bag. The resident involved had diagnoses including neuromuscular dysfunction of the bladder and congestive heart failure, and had a physician's order for an indwelling catheter. The improper placement of the catheter bag was confirmed by the Director of Nursing, who acknowledged that the bag should not be in contact with the floor. These findings were based on policy review, clinical record review, direct observation, and staff interview.
Plan Of Correction
As part of catheter care, resident 15 was provided a catheter bag holder to ensure the catheter is positioned properly. Each resident with a Foley will be monitored by the resident care coordinator and/or infection control nurse. Monitoring will be done weekly for one month and then monthly. Staff is being in-serviced currently on proper catheter care and it will be included with their annual competency training. Audits will be reviewed at QAPI. Monitored by Director of Nursing.