Catheter Collection Bag Not Maintained Off Floor
Penalty
Summary
Facility staff failed to maintain proper positioning of an indwelling urinary catheter collection bag for a resident diagnosed with paraplegia and obstructive uropathy, who was totally dependent on staff for turning and positioning. On multiple occasions, the resident was observed sitting up in bed with the catheter collection bag lying completely on the floor. These observations occurred on two consecutive days, despite the resident having a physician's order to maintain a straight drain catheter and being cognitively intact for making daily decisions. Interviews with both an LPN and a CNA confirmed that catheter bags should not be in contact with the floor due to infection risks. Review of the facility's urinary catheter care policy also specified that catheter tubing and drainage bags must be kept off the floor to prevent catheter-associated complications, including urinary tract infections. The deficiency was communicated to facility administrative and clinical leadership, and no additional information was provided prior to exit.