Failure to Maintain Urinary Catheter Drainage Bags Off the Floor
Penalty
Summary
The facility failed to maintain indwelling urinary catheter drainage bags in a manner that would prevent infections, as observed in two out of three residents reviewed for urinary catheters. For one resident with multiple chronic conditions including chronic respiratory failure, heart disease, diabetes, and impaired cognition, the urinary drainage bag was observed lying directly on the floor of the resident's room. This observation was confirmed by an LPN during an interview. Similarly, another resident with a history of aphasia, heart disease, neuromuscular bladder dysfunction, and other significant medical issues was found with their urinary drainage bag also lying directly on the floor. This was verified by a CNA during an interview. Review of the facility's urinary catheter care policy indicated that catheter tubing and drainage bags should be kept off the floor, but this protocol was not followed in these instances.