Failure to Maintain Proper Catheter Bag Placement for Infection Control
Penalty
Summary
A deficiency was identified when a resident with a suprapubic catheter was observed with their catheter bag placed on the floor while sitting in a wheelchair. The bag remained on the floor for an extended period and was later hooked onto the wheelchair strap but continued to touch the floor. The nursing assistant confirmed the improper placement and stated that a cover for the catheter bag was available but had not been used at the time, as it was left in the resident's room. The resident had significant medical conditions, including severe cognitive impairment, neurogenic bladder, diabetes, dementia, and was at risk for pressure ulcers. The care plan and physician orders required staff to provide catheter care per policy and ensure infection prevention measures were followed. The facility's Infection Prevention and Control Program directed staff to prevent infection by adhering to proper techniques, but staff failed to ensure the catheter bag was kept off the floor as required.