Failure to Keep Urinary Catheter Drainage Bag Off Floor
Penalty
Summary
A deficiency occurred when staff failed to keep a urinary catheter drainage bag off the floor for a resident with a suprapubic catheter due to neurogenic bladder. The resident, who was moderately cognitively impaired and had a history of overactive bladder and neuromuscular dysfunction, was observed twice in one day with the catheter drainage bag lying directly on the floor, first when it was half full and later when it was full. The care plan for this resident specified that the catheter bag should be positioned below the bladder and away from the entrance, with tubing checked for kinks each shift. Staff interviews revealed that the assigned nurse aide was aware the drainage bag could not be attached to the bed frame and had notified the nurse at the beginning of the shift, but did not take further action to secure the bag or obtain a privacy bag until prompted. The assigned nurse also acknowledged awareness of the issue but had not changed the drainage bag due to lack of time. Both the Infection Preventionist and the DON confirmed that catheter drainage bags should not be on the floor for infection control reasons, and the Administrator was unable to explain why the issue had not been addressed despite staff awareness.