Failure to Maintain Sanitary Catheter Care
Penalty
Summary
A deficiency occurred when staff failed to maintain a resident's indwelling suprapubic urinary catheter in a safe and sanitary manner. The resident had multiple diagnoses, including major depressive disorder, diabetes mellitus, chronic kidney disease, and congestive heart failure, and required substantial to maximal assistance with activities of daily living. The resident's care plan and urinary incontinence assessment specifically instructed staff to monitor the catheter for infection and skin breakdown, ensure the catheter drainage bag and tubing were secured in a privacy bag, and prevent the bag from touching the floor. Despite these instructions, observations on multiple occasions showed the resident's urinary catheter collection bag lying directly on the floor with visible urine in the bag and tubing, rather than being hung on the bedframe as required. Staff interviews confirmed that facility policy required catheter collection bags to be placed in a privacy bag and kept off the floor, and that the system should be maintained in a sanitary manner to prevent infections. The facility's policy also emphasized the importance of maintaining unobstructed urine flow and frequent emptying of the catheter bag. However, the observed failure to follow these procedures resulted in the resident's catheter bag being left on the floor for extended periods, contrary to both the care plan and facility policy.