Failure to Maintain Proper Catheter Bag Placement and Infection Control
Penalty
Summary
The facility failed to maintain proper infection control practices regarding the placement of a catheter bag for a resident with an indwelling catheter. The resident, who had diagnoses including acute kidney failure, urinary retention, type 2 diabetes mellitus with a foot ulcer, and depression, was observed multiple times sitting in a wheelchair with the catheter bag placed under the wheelchair and touching the floor. These observations occurred on several occasions, and staff interviews confirmed that the catheter bag was not properly secured and was in contact with the floor. The facility's policy states that if a catheter bag or tubing touches the floor, it is considered contaminated and should be replaced or disinfected, and the bag should be elevated off the floor. Staff interviews revealed that temporary staff often did not hang the catheter bag properly, and both a CNA and an RN acknowledged that the bag should not be touching the floor due to contamination risks. The DON also confirmed that the catheter bag should be placed in a covered bag and elevated above the floor. Despite these policies and staff awareness, the deficiency occurred due to failure to consistently follow infection control protocols for catheter bag placement.