Failure to Prevent Biliary Drainage Leak and Maintain Infection Control
Penalty
Summary
A deficiency occurred when a resident with a biliary drain was found to have biliary fluid on the floor beneath their drainage bag. The resident, who had diagnoses including bladder cancer and anemia, required substantial to maximal assistance for mobility and had an order in place to monitor and document biliary drain output three times daily. Documentation showed the drain output was being recorded, but during an observation, yellow liquid from the biliary drain was seen on the floor. The LVN present confirmed that each nurse is responsible for emptying the drainage bag during their shift and acknowledged that the drainage should not be leaking onto the floor. The Director of Nursing confirmed that biliary fluid should not be present on the floor due to infection control concerns, as organisms in the fluid could be a source of illness or infection and could be transmitted by contact. The facility's policy on biliary drain management emphasized the importance of proper care to prevent infection and ensure appropriate drainage. The failure to prevent biliary drainage from leaking onto the floor constituted a lapse in infection control practices for the resident requiring biliary drain care.