Failure to Maintain Proper Foley Catheter Bag Storage
Penalty
Summary
Surveyors observed that a resident with multiple medical conditions, including severe dementia, neuromuscular bladder dysfunction, and a history of urinary tract infections (UTIs), had a Foley catheter bag that was repeatedly found lying on the floor. The facility's own urinary catheter care policy, as presented by the DON, specifically requires that catheter tubing and drainage bags be kept off the floor to prevent catheter-associated UTIs. Despite this, on two separate occasions, the resident's Foley catheter bag was observed on the floor, both times while the resident was under enhanced barrier precautions. Review of the resident's medical record confirmed the ongoing use of an indwelling catheter and documented recent treatment for UTIs, including one with E. coli. The resident's care plan included instructions to position the catheter bag and tubing below the bladder and away from the room entrance, but did not specify to keep it off the floor. During interviews, facility staff acknowledged that the catheter bag should not have been on the floor and confirmed the observations. The repeated failure to properly store the Foley catheter bag constituted a breach of infection control standards as outlined in the facility's policy.