F0880

D

Failure to Maintain Urinary Catheter Bag Off the Floor

Ormond Beach, Florida Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The facility failed to maintain an infection prevention and control program by not ensuring that a resident’s indwelling urinary catheter drainage bag was kept off the floor, as required by facility policy and the resident’s care plan. On multiple observations over several days, the resident was seen lying in bed with the urinary catheter bag positioned on the door side of the bed and resting on the floor, with photographic evidence obtained on several of these occasions. The resident had diagnoses including an encounter for fitting and adjusting a urinary device, an active physician order for an indwelling urinary catheter with instructions to use a catheter tube securing device and adjust its position as needed, and a care plan identifying the resident as at risk for urinary tract infection related to incontinence and the presence of an indwelling catheter, with an intervention to position the catheter bag and tubing to promote dignity and drainage.

During an interview, the CNA responsible for the resident’s care stated that catheter care involved ensuring there were no kinks in the tubing, emptying the bag, and reporting output to the nurse, and acknowledged that the urinary drainage bag should not touch the floor. When asked to observe the resident’s catheter bag while it was resting on the floor, the CNA confirmed that it was on the floor and explained that sometimes when beds are in a low position, the bags will touch the floor. The resident’s quarterly MDS showed a BIMS score of 6 out of 15, indicating severe cognitive impairment. The facility’s catheter care policy required that the drainage spigot not touch the floor, that tubing be free of kinks, and that the catheter be kept at an appropriate level to promote urine flow and maintain dignity, which was not followed in this case.