Failure to Keep Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
The deficiency involves the facility’s failure to maintain a urinary catheter drainage bag off the floor for a resident with an indwelling urinary catheter. The resident had neuromuscular dysfunction of the bladder and a physician’s order for an indwelling catheter due to neurogenic bladder with urinary retention. The resident’s MDS documented severely impaired cognition and total dependence for most ADLs, and the care plan specified that the catheter tubing should be free of kinks or obstruction and the drainage bag kept in the proper location. During an observation, the resident was found in bed with the bed in a low position and the urinary catheter drainage bag lying flat on the floor. In a subsequent observation and interview, a nurse aide acknowledged that the catheter drainage bag was on the floor and stated she had been educated to hang the bag on the metal bed frame but reported it often fell off when the bed was in a low position. When the unit manager attempted to hang the bag on the bed frame, the drainage bag still touched the floor, and the manager stated the bed would need to be raised to prevent this and that the bag should never touch the ground due to possible contamination and germs. The ADON and DON both stated that it was never acceptable for a urinary catheter drainage bag to touch the ground and that staff had been educated on catheter care, confirming that the observed condition did not meet the facility’s expectations for catheter bag positioning.
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