Failure to Maintain Indwelling Catheter Bag Off Floor and Covered
Penalty
Summary
The facility failed to follow its own catheter care policy for a resident with an indwelling urinary catheter. The policy dated 11/2024 required that residents with indwelling catheters receive appropriate care, including maintaining catheter drainage bags off the floor, ensuring the catheter is anchored, and keeping the drainage bag covered and properly positioned. Resident R1, admitted on 12/24/25 with diagnoses including bronchitis, hypertension, and diabetes, was identified in the clinical record as currently receiving a seven-day course of antibiotics for a urinary tract infection. During an observation on 1/27/26 at 11:44 a.m., Resident R1’s urinary catheter drainage bag was seen lying uncovered on the floor under the bed, without any covering over the bag. In an interview at 11:50 a.m., an LPN (Employee E3) confirmed that the catheter bag was on the floor and acknowledged that the bag should be covered and maintained off the floor for infection control. In a separate interview at 12:40 p.m., the Nursing Home Administrator also confirmed that the catheter bag should be covered and not touch an unclean surface due to the risk of infection. These observations and interviews established that the facility did not ensure essential catheter care and infection prevention measures for this resident.
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