Catheter Bag Found on Floor Violates Infection Control Policy
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for a resident with an indwelling urinary catheter. On the date of observation, the resident’s catheter bag was found hanging off the side bed rail with the bottom of the bag resting on the floor. The resident, who had diagnoses including hemiplegia, chronic kidney disease, heart failure, obstructive uropathy, and atrial fibrillation, was unable to see the catheter bag from his position and was unaware it was on the floor. Multiple staff interviews confirmed that the catheter bag being on the floor was an infection control issue, as it could expose the bag and tubing to bacteria and create a risk for infection, especially given the resident’s immunocompromised status. Record review showed that the resident’s care plan included monitoring for signs and symptoms of urinary tract infection and that the facility’s policy required catheter bags and tubing to be kept off the floor. Staff, including RNs, LVNs, and the administrator, acknowledged during interviews that the catheter bag on the floor was a violation of infection control practices and could lead to contamination. The facility’s own policy, updated in July 2024, specifically stated that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated urinary tract infections.