Failure to Maintain Proper Foley Catheter Bag Positioning and Infection Control
Penalty
Summary
A deficiency was identified when a resident with a complex urological history, including recent urinary surgery, urogenital implants, and a current indwelling Foley catheter, was observed with improper catheter bag positioning on two separate occasions. On one occasion, the resident's catheter bag was placed on their lap above bladder level while being brought to the dining room, which was confirmed by an LPN who acknowledged the issue. The resident had just returned from a urology appointment, and the improper positioning was not corrected until after the surveyor's observation. On another occasion, the same resident's Foley catheter drainage bag was found clipped to the bottom of the wheelchair, with half of the bag uncovered and resting on the floor. A CNA who provided morning care recognized that the catheter bag should have been placed in a privacy bag on the back of the wheelchair, as per facility policy. The facility's own catheter care policy requires that the drainage bag be kept below bladder level and off the floor at all times, but these standards were not maintained during the observed incidents.