Catheter Drainage Bag Found on Floor for Resident with Indwelling Catheter
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed multiple times throughout the morning and early afternoon with the catheter drainage bag positioned on the floor and partially under the bed, despite being covered with a privacy bag. The resident had a history of urinary tract infection, chronic kidney disease, bacteremia, and pyonephrosis, and was severely cognitively impaired and dependent for mobility. Physician orders and the care plan specified that the catheter bag should be positioned below the level of the bladder and away from the entrance, with tubing checked for kinks, but did not direct that the bag should be on the floor. Staff interviews confirmed awareness that the catheter bag should not be touching the floor. The nursing aide assigned to the resident stated she had previously hung the bag on the side of the bed and was unsure how it ended up on the floor, noting the resident could not reach the bag. The nurse assigned to the resident was unaware of the bag's position and stated she only assessed catheters once per shift. The DON and Administrator acknowledged the issue, with the DON suggesting the bag clip may have been broken and the Administrator noting difficulty keeping bags off the floor when the bed is in the lowest position.