Failure to Maintain Catheter Bag Off Floor as Required by Infection Control Policy
Penalty
Summary
A deficiency was identified when a resident with a history of sepsis due to streptococcus pneumoniae, recurrent urinary tract infections, vesicoureteral reflux, dementia, and Parkinson's disease was observed with an indwelling urinary catheter bag that was not properly maintained according to facility policy and physician orders. The resident's care plan and physician orders specified that the catheter bag should be kept in a privacy (dignity) bag and off the floor at all times. However, during observation, the catheter bag was found visible from the doorway, not in a dignity bag, and touching the floor while the resident was in bed. Interviews with staff confirmed that the catheter bag should have been inside a dignity bag and placed in a basin to prevent contamination from the floor. The CNA interviewed was unsure who had corrected the issue after it was observed, and the DON acknowledged that the catheter bag should not be on the floor due to infection risk. Review of the facility's catheter care policy also confirmed the requirement to keep catheter tubing and drainage bags off the floor. These findings demonstrate a failure to follow established infection prevention and control protocols for catheter care.