Failure to Maintain Sanitary Foley Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the care of a resident with an indwelling Foley catheter. Observations on two separate dates revealed that the resident's catheter drainage bag was not attached to the bed and was lying directly on the floor without any protective barrier. This practice was not in accordance with both CDC guidelines and the facility's own policy, which require that catheter bags be kept off the floor and below the level of the bladder to prevent contamination. The resident involved had a history of urinary retention and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling urinary catheter. Documentation confirmed the presence of physician orders and care plans for catheter care. Interviews with multiple staff members, including CNAs, a nurse, and the Director of Nurses, consistently indicated awareness that catheter bags should be hanging from the bed or wheelchair and not resting on the floor. Despite this, the deficiency was observed during the survey.