Failure to Secure Catheter Bag Compromises Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for one resident reviewed for infection control. Specifically, a resident with multiple diagnoses, including type 2 diabetes, acute kidney failure, and obstructive uropathy requiring an indwelling urinary catheter, was observed with her catheter drainage bag resting on the floor while she was asleep in bed. Facility records indicated that catheter care orders required anchoring the tubing and checking skin integrity every shift and as needed. The resident's care plan also included interventions to monitor catheter placement and signs and symptoms of urinary tract infection. Despite these documented protocols, the catheter bag was not properly secured, resulting in it coming into contact with the floor. Interviews with multiple staff members, including CNAs and an LVN, confirmed that all nursing staff were responsible for ensuring catheter bags were not on the floor and that staff were expected to round on residents every two hours. Staff acknowledged that a catheter bag on the floor posed an infection risk and that this was not in accordance with facility policy or proper protocol. The facility's infection control policy emphasized maintaining a safe and sanitary environment to prevent the transmission of communicable diseases, but this was not followed in the observed incident.