Catheter Bag Not Properly Secured, Leading to Infection Control Deficiency
Penalty
Summary
A deficiency was identified when a resident with an indwelling catheter was observed with their catheter bag lying on the floor instead of being properly hooked to the bed. The resident, a male with a history of diabetes mellitus and cerebrovascular accident, had moderately impaired cognition and was on enhanced barrier precautions. Facility records and care plans specified that the catheter bag should be positioned below the level of the bladder, in a privacy bag, and anchored to the bed or wheelchair to prevent pulling and contamination. Despite these instructions, direct observation revealed the catheter bag on the floor, and a licensed vocational nurse (LVN) was seen entering the room, noticing the issue, and then hooking the bag to the bed. Multiple staff interviews confirmed that catheter bags should never be on the floor due to concerns about cross-contamination and infection control. Staff, including LVNs, RNs, the Assistant Director of Nursing (ADON), Nurse Practitioner (NP), and Director of Nursing (DON), all acknowledged that it was everyone's responsibility to ensure catheter bags were properly hung. It was also noted that the resident had a habit of unhooking the catheter bag when repositioning, which contributed to the issue, but staff reiterated that maintaining proper placement of the catheter bag was necessary to prevent infection.