Failure to Maintain Catheter Privacy and Tubing Position per Infection Control Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its catheter care and infection prevention procedures for a resident with an indwelling Foley catheter. The facility’s Catheter Care Procedure, last revised June 2020, required that catheter drainage bags be kept below the level of the bladder, off the floor, and covered with a privacy bag when the resident is out of bed. The resident, originally admitted with dementia and bladder neck obstruction and assessed with a BIMS score indicating severe cognitive impairment, had physician orders for an indwelling Foley catheter PRN for chronic urinary retention. During a lunch observation in the dining room, the resident was seen sitting in a wheelchair with the catheter drainage bag uncovered, without the required privacy bag. In a separate observation in a common TV area, the same resident was seen in a wheelchair with the urinary catheter tubing touching the floor, contrary to the facility’s policy to keep tubing off the floor. Staff interviews confirmed that these practices did not meet facility expectations: a CNA stated that all residents should have a privacy bag covering their urinary drainage bags, another CNA reported that the previous CNA had forgotten to attach the catheter bag to the chair and acknowledged that the tubing should not be dragged on the floor, and both the DON and the Administrator confirmed that catheter tubing should not touch the ground and that a privacy bag should always be in place when residents are out of their rooms. These observations and statements demonstrate that the facility did not maintain its infection prevention and control program for this resident’s catheter care.
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