Failure to Maintain Proper Positioning of Urinary Drainage Bag
Penalty
Summary
A facility failed to provide appropriate care and services to prevent urinary tract infection (UTI) for a resident with an indwelling urinary catheter and a history of recurrent UTIs. The resident was readmitted with a physician's order for an indwelling urinary catheter due to neurogenic bladder. Medical records indicated the resident had a recent change in condition, including increased sleepiness, and was subsequently treated for a UTI with IV antibiotics as ordered by the physician. During observations on two separate days, the resident's urinary drainage bag was found lying on the floor while the resident was in bed. Staff interviews confirmed that the drainage bag should not be in contact with the floor for infection prevention, and staff acknowledged the improper positioning of the bag. The failure to keep the urinary drainage bag off the floor was not in accordance with CDC guidelines for catheter maintenance and posed a risk for catheter-associated urinary tract infection (CAUTI).
Plan Of Correction
F690 Bowel/Bladder Incontinence, Catheter, UTI How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The resident's indwelling catheter bag was checked on 6/19/25 by the ADON for proper positioning and the bag was not touching the floor at the time. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: An audit of residents with indwelling urinary catheters was completed on 6/23/25 by the infection prevention and control nurse. One other resident was identified with an indwelling urinary catheter. Positioning for the collection bags was checked. The collection bags were not touching the floor. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur: In-service was initiated on 6/23/25 provided by DSD to the staff regarding catheter care. In-service will be completed by 7/11/25 regarding proper positioning and catheter care. I.P. will observe residents with indwelling catheters 3 times per week for 3 months if the collection bags are touching the floor and for proper positioning. Findings will be addressed immediately. How the facility plans to monitor its performance to make sure that solutions are sustained: The POC is integrated into the QA system. The DON/designee will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/11/25