Failure to Maintain Proper Catheter Drainage Bag Positioning
Penalty
Summary
A deficiency was identified when a resident with a history of neurogenic bladder, urinary retention, and an indwelling Foley catheter was not provided appropriate catheter care to prevent urinary tract infections. The resident's medical record indicated a recent urinary tract infection, for which antibiotics were prescribed. During an observation, the resident's Foley catheter drainage bag was found lying on the floor under the bed. The resident was unaware that the bag was on the ground. Facility policy required that catheter drainage bags be kept off the floor and secured below the level of the bladder. Interviews with nursing staff, the Director of Clinical Operations, and the Administrator confirmed that all staff were responsible for ensuring catheter drainage bags were kept off the ground. Staff acknowledged that failure to do so could lead to infection and injury. The facility's policy and care plan interventions specifically directed staff to keep the drainage bag off the floor, but this was not followed, resulting in a deficiency related to catheter care and infection prevention.