Failure to Maintain Catheter Tubing and Drainage Bags Off the Floor
Penalty
Summary
The facility failed to prevent the risk of urinary tract infection by not ensuring that urinary catheter tubing and drainage bags were kept off the floor for two residents with indwelling catheters. One male resident with a history of stroke and gross hematuria was observed lying in bed with his catheter bag resting directly on the floor without a barrier. This was confirmed by an LPN, who subsequently placed a towel under the bag. The clinical nurse supervisor confirmed the resident had a Foley catheter, which had last been changed the previous month. A female resident with dementia, insomnia, and diabetes was observed self-ambulating in her wheelchair with her catheter bag in a privacy bag, but with approximately 12 inches of catheter tubing dragging on the floor. Multiple observations confirmed that both the tubing and the privacy bag containing the catheter bag were in contact with the floor as she moved around the facility. The urine in the tubing appeared dark yellow, orange-tinged, and cloudy. Staff interviews confirmed that this resident had recurrent urinary tract infections, and a recent urinalysis showed evidence of infection. Facility policy requires that catheter tubing and drainage bags be kept off the floor, but this was not followed in these cases.