Failure to Secure Urinary Leg Bags and Lack of Infection Surveillance
Penalty
Summary
The facility failed to ensure that a resident's urinary leg bags were effectively secured, resulting in the leg bag dragging on the floor and being rolled over by the resident's wheelchair. The resident, who had moderate cognitive impairment and multiple medical conditions including nephrostomy tubes, was observed with the urinary leg bag on the floor, and staff did not immediately secure it. Staff interviews revealed that the straps provided for securing the leg bag were not suitable, and alternative straps had not been made available, leading to improper securing of the bag. The care plan and CNA work list lacked specific instructions for the management and securing of nephrostomy bags, and the facility's policy did not address proper placement or securing of urinary drainage bags. Additionally, the facility did not conduct ongoing surveillance for infection control to track and trend symptomatic illnesses among residents who were not on antibiotics. The DON, who also served as the infection preventionist, relied on mental notes from reviewing progress notes rather than maintaining a written list or using a formal process to monitor symptomatic residents. There was no system in place to track or trend symptoms, and staff illnesses were not regularly discussed or compared with resident illnesses to identify potential outbreaks. Facility policies referenced the use of surveillance tools for infection control, but in practice, these tools were not utilized to record or monitor infections, symptomatic illnesses, or staff illnesses. The lack of documentation and formal tracking limited the facility's ability to recognize and respond to infection trends, potentially affecting all residents in the facility.