Failure to Maintain Catheter Bag Placement and Infection Control
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices for two residents with indwelling Foley catheters. Observations revealed that both residents had their catheter drainage bags in direct contact with the floor. One resident's catheter bag was hanging on the side of the bed without a privacy cover, with the bottom of the bag touching the floor. The other resident's catheter bag was found lying flat on the floor under the bed and was visible from the doorway. Both residents had care plans and physician orders specifying that catheter bags should be kept off the floor and in privacy bags, but these interventions were not followed during the observed incidents. Record reviews indicated that both residents had significant medical histories, including chronic kidney disease, urinary retention, and neuropathic bladder, necessitating the use of indwelling catheters. Their care plans included specific interventions to prevent infection, such as maintaining the catheter bag off the floor, monitoring for signs and symptoms of urinary tract infection, and ensuring the use of privacy bags. Despite these documented interventions, staff failed to implement them as required. Interviews with staff, including CNAs and the DON, confirmed awareness of the risks associated with improper catheter bag placement, specifically the increased risk of infection. However, review of the facility's infection control and catheter care policies revealed no guidance regarding the need to keep catheter bags off the floor. This lack of policy detail, combined with observed staff inaction, contributed to the deficiency in infection prevention and control for residents with indwelling catheters.