Failure to Provide Proper Catheter Care and Maintain Drainage Bag Position
Penalty
Summary
Surveyors identified deficiencies in the facility's management of indwelling urinary catheters for three residents. For two residents, the urinary catheter drainage bags were observed touching the floor during routine observations. In one instance, a resident's drainage bag was seen hanging on the side of the bed and making contact with the floor. In another case, the drainage bag was also found on the floor, and staff acknowledged that the bag should have been placed in a basin to prevent this. These observations were confirmed by nursing staff, who recognized that the drainage bags were not properly positioned as required by facility policy. For a third resident, the facility failed to provide indwelling urinary catheter care as outlined in the resident's care plan. The care plan specified that catheter care should be provided as ordered, but there was no physician's order for catheter care in the resident's medical record. Additionally, there was no documentation to show that catheter care had been performed. The resident had a history of urinary tract infections and severe cognitive impairment, and was admitted and readmitted to the facility with an indwelling urinary catheter. Nursing staff confirmed the absence of both the required physician's order and documentation of catheter care. The facility's policy required that catheter care be performed every shift and as needed, and that drainage bags not touch the floor. The failures to follow these protocols were acknowledged by nursing staff and administration during interviews. These lapses in care and documentation had the potential to contribute to the development of urinary tract infections among residents with indwelling catheters.
Plan Of Correction
Department heads and designee will do daily room rounds to make sure no indwelling catheter bag is touching the floor. Any non-compliance will be addressed immediately and reported to the morning meeting. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON will monitor the effectiveness of the process and report to the Administrator. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025