Urinary Drainage Bag Not Maintained in Sanitary Position
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices by not maintaining a urinary drainage bag in a sanitary manner for a resident with a suprapubic catheter. On multiple occasions, direct observation revealed that the resident's covered urinary drainage bag was touching the floor at the bedside. The resident had significant medical conditions, including paraplegia, a stage 3 sacral pressure ulcer, urinary retention, neuromuscular dysfunction of the bladder, and chronic kidney disease, and was assessed as having severe cognitive impairment. The care plan required catheter care every shift and specified that the urinary drainage bag should be maintained below the bladder level to facilitate urine flow. Staff interviews confirmed that the drainage bag should not have been in contact with the floor. The facility's policy also required appropriate treatment and services to prevent urinary tract infections.