Catheter Drainage Bag Found Resting on Floor for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident with a history of hydronephrosis, urogenital implants, and neuromuscular dysfunction of the bladder, who was dependent on staff for all activities of daily living and had an indwelling suprapubic catheter, was observed multiple times with their urinary catheter drainage bag resting on the floor. The resident's care plan included interventions to keep the urinary collection bag below the level of the bladder, but did not specify that the bag should not touch the floor. During three separate observations over consecutive days, the catheter bag was seen hanging from the bedframe with the entire bottom of the bag in contact with the floor while the bed was in a low position. Staff interviews confirmed awareness of the requirement to keep catheter bags off the floor to prevent infection. A nurse aide reported having noticed the bag on the floor several times and repositioning it, while the DON stated that staff had been educated on this practice and that hooks were available for proper placement. The unit manager also acknowledged the expectation that the drainage bag should not touch the floor and described a temporary measure taken to prevent contact with the floor.