Improper Foley Catheter Bag Placement on Floor
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper urinary catheter bag placement for one resident. The resident had multiple medical conditions, including sequelae of cerebral infarction, chronic respiratory failure, acute pulmonary edema, type 2 diabetes mellitus, immunodeficiency, and a neurogenic bladder requiring an indwelling catheter. The resident’s care plan included interventions for indwelling catheter care, such as positioning the catheter bag and tubing below the level of the bladder and away from the entrance door, and using a privacy cover on the Foley bag. The admission MDS showed the resident was severely cognitively impaired. Physician orders directed indwelling catheter care. Despite these orders and care plan interventions, observations on the survey date showed the catheter drainage bag placed under the bed on the floor, with the catheter tubing touching the full surface of the floor, covered by a blue privacy bag. During interviews, a CNA stated that catheter care involved using appropriate PPE, changing urine drainage bags, cleaning the genitourinary area, and recording urine output, and acknowledged that the catheter should never be on the floor because it could pose a risk of infection. An RN reported that catheter care was performed every shift by CNAs or nurses and stated that the catheter should not touch the floor, and that the tubing should hang to the side of the bed covered with a dignity bag. The DON explained that CNAs were responsible for cleaning and emptying the Foley catheter, placing a privacy bag on the catheter, and ensuring it was hung up so it did not touch the floor, and stated that catheters should not be left on the floor. Facility policies on catheter care and the infection prevention and control program, as well as CDC guidance, specified that the collection bag should be kept below the level of the bladder and not rest on the floor. The observed placement of the catheter bag and tubing on the floor for this resident was inconsistent with the care plan, staff statements, facility policy, and CDC standards.
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