F0690

D

Improper Positioning of Urinary Drainage Bag on Floor

Windsor, North Carolina Survey Completed on 01-30-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain proper positioning of a urinary drainage bag to prevent infection for a resident with a suprapubic catheter. The resident was admitted with neuromuscular dysfunction of the bladder and had a care plan intervention to keep the catheter bag covered for dignity and positioned below the level of the bladder and away from the entrance door. A quarterly MDS documented that the resident was severely cognitively impaired and had an indwelling suprapubic catheter. During an observation, the resident was lying in bed with the bed in the lowest position and the catheter bag lying on the floor, wedged between the floor and the bed frame, with no tension on the catheter tubing. A subsequent observation the same day showed the bed had been raised slightly, but the catheter bag remained on the floor with no barrier between it and the floor.

In interviews, the NA assigned to the resident stated the catheter bag was secured to the bedframe and below the bladder, and suggested it may have fallen to the floor when the bed was lowered for feeding, acknowledging that the bag was not supposed to touch the floor. She reported checking on the resident before lunch and again mid-afternoon and stated the bag was not on the floor at those times. A nurse reported that when she arrived for her shift that morning, she found the catheter bag on the floor and placed it back on the bedframe, and did not reassess its position later that day. The DON/Infection Preventionist stated staff likely did not understand that lowering the bed could cause the catheter bag to rest on the floor and described that the bag should be kept several inches off the floor. The Administrator stated that everyone should know the catheter bag should not be touching the floor and could not explain why the NA did not identify the bag on the floor.