Catheter Collection Bag Found on Floor
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and an indwelling urinary catheter was observed on two separate occasions with their urinary catheter collection bag lying on the floor, both in the dining area and in bed. The bag was covered for privacy, but its placement on the floor was directly observed by surveyors. Staff interviews revealed that nursing assistants and nurses were aware that catheter bags should not be on the floor and should be hung below the bladder, but none reported seeing the bag on the floor during their shifts. The Assistant Director of Nursing and the Physician Assistant both confirmed that it was unacceptable for the catheter bag to be on the floor due to the increased risk of infection. Record review indicated that the resident's care plan included a goal to prevent complications or injury related to catheter use. Training records showed that staff had received education on catheter care, but the provided training materials did not specifically address the proper placement of the catheter collection bag. Despite staff knowledge and training, the deficiency occurred due to the failure to ensure the catheter bag was consistently kept off the floor, as required for infection prevention.