Failure to Maintain Catheter Bag and Tubing Off Floor
Penalty
Summary
The facility failed to implement and maintain an infection prevention and control program as required by policy and resident care plans. Specifically, the facility did not ensure that a resident's indwelling catheter bag and tubing were kept off the floor, as observed on multiple occasions. The facility's policy and the resident's care plan both specified that catheter bags and tubing should not touch the floor to prevent contamination, yet observations on two separate days showed the catheter tubing and bag resting on the floor while the resident was in her room. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the catheter bag and tubing were found on the floor and acknowledged that this was not in accordance with facility policy or infection control standards. The resident involved had a physician's order for Foley catheter care every shift and a care plan approach to prevent the tubing or drainage system from touching the floor, but these measures were not followed during the observed periods.