Failure to Maintain Proper Catheter Bag Placement and Adherence to Infection Control Policy
Penalty
Summary
A deficiency was identified regarding the care of a resident with an indwelling urinary catheter. The resident, who had a diagnosis of benign prostatic hyperplasia and was dependent on staff for toileting hygiene, had a care plan that did not specify instructions for proper placement of the catheter urine bag and tubing to prevent them from touching the floor. Despite documentation indicating the resident had been educated to keep the urine bag lower than the bladder and off the floor, multiple observations showed the catheter urine bag either lying on the floor or attached to the bed rail but still touching the floor. Additionally, the urine bag was not covered with a dignity bag during these observations. Staff interviews confirmed that the expectation was for the catheter urine bag not to touch the floor while attached to the bed. Review of CDC guidelines and the facility's own policy both directed that catheter bags and tubing should not be allowed to touch the floor and should be covered. The lack of clear care plan direction and repeated failure to maintain proper catheter bag placement led to noncompliance with both facility policy and national infection prevention guidelines.