Failure to Maintain Infection Control: Catheter Bag on Floor and Food in Linen Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by two specific deficiencies. First, staff did not ensure that an indwelling urinary catheter drainage bag for a resident with multiple complex medical conditions, including end stage renal disease, diabetes, dementia, and sepsis, was kept off the floor. Observations on two separate occasions found the drainage bag resting on the floor when the resident's bed was in its lowest position. Both a Licensed Vocational Nurse and a Registered Nurse acknowledged that this practice was not in accordance with facility policy and posed an infection control risk, as bacteria from the floor could contaminate the bag and potentially lead to infection. The facility's own procedures and policies explicitly required that catheter drainage bags be kept off the floor to prevent catheter-associated urinary tract infections. Additionally, the facility failed to maintain sanitary storage practices in the clean linen closet. During an inspection, food items including a bagel, banana, and a bottle of Gatorade were found stored alongside clean linens, beddings, towels, gowns, and residents' personal clothes. The Maintenance Supervisor confirmed that these food items belonged to an assistant and admitted to having previously instructed the assistant not to store food in the linen closet. The Director of Nursing also confirmed that food should not be stored in this area, as it could attract insects and compromise the cleanliness of residents' clothing and linens. Review of facility policies indicated that all housekeeping and laundry storage areas were to be kept clean and free from trash, rubbish, and other contaminants at all times. The presence of food in the clean linen storage and the improper handling of the catheter drainage bag both represented failures to follow established infection control procedures, as documented in the facility's own policies and procedures.