Improper Foley Catheter Bag Positioning and Infection Control Lapse
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program by not ensuring proper positioning of an indwelling Foley catheter drainage bag for one resident. The resident was an adult male with cerebral palsy, profound intellectual disabilities, neuromuscular dysfunction of the bladder, severe cognitive impairment (BIMS score of 0/00), range of motion impairment in all extremities, wheelchair use, and dependence for self-care and mobility. He had an indwelling catheter in place for a neurogenic bladder, with an active order for the catheter and a care plan addressing the indwelling catheter. During observations, the resident was seen in bed with his Foley catheter bag hung vertically with the bottom of the bag touching the floor. Staff interviews confirmed that the observed Foley bag position was inconsistent with facility expectations and training. A CNA who normally worked on the resident’s hall stated that Foley bags were supposed to be set up under the bed on the side, vertical, in a privacy bag, and not touching the floor, and acknowledged that a bag touching the floor would be considered contaminated. An RN stated that nurses were responsible for ensuring Foley bags did not touch the floor, that the bag should be lower than the resident, hung on a non-movable part of the bed, and not touching the floor due to contamination risk. The DON stated that nurses and CNAs were responsible for ensuring Foley bags were appropriately placed or in a basin so they did not touch the floor, and that it would be an infection control concern if the bag touched the floor, although she later stated she did not believe the bag touching the floor would have impacted this resident because the bag was enclosed. The facility’s catheter care policy stated it was the policy to ensure residents with indwelling catheters receive appropriate catheter care, but the observed practice did not align with this standard.
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