Failure to Maintain Catheter Drainage Bags Off the Floor Under Infection Control Program
Penalty
Summary
The deficiency involves the facility’s failure to maintain an infection prevention and control program related to the management of indwelling urinary catheter drainage bags for three residents. For one resident, an older female with diagnoses including disorder of the urinary system, chronic viral Hepatitis C, hypokalemia, acute kidney disease, and cirrhosis of the liver, surveyors reviewed records showing she had an indwelling suprapubic catheter. Her care plan and physician orders directed that the catheter bag and tubing be positioned below the level of the bladder, kept off the floor, and placed in a privacy bag. During an interview and observation while the resident was in bed with a family member present, the resident’s catheter bag was observed lying on the floor, contrary to the documented orders and care plan. A second resident, an older male with diagnoses including type 2 diabetes, thrombocytopenia, and benign prostatic hyperplasia with lower urinary tract symptoms, also had an indwelling catheter. His orders and care plan similarly required that the Foley bag be kept in a privacy bag while in bed or wheelchair, positioned below the bladder, and maintained off the floor with tubing checked for kinks. During observation, this resident was found asleep in bed with the catheter bag inside a blue privacy bag on the right side of the bed. The bag was not hooked to the bedrail and was lying sideways with the tubing on the floor, in direct conflict with the facility’s catheter care policy and the resident’s individualized care plan. A third resident, an older male with chronic kidney disease, conversion disorder with seizures, viral hepatitis C, dementia, type 2 diabetes, and a history of UTI, also had an indwelling catheter. His orders and care plan required that the Foley bag be in a privacy bag every shift, positioned below the bladder, and kept off the floor to prevent catheter-related trauma. During observation, this resident was in bed and became aggressive when the investigator attempted conversation. The catheter bag was found on the right side of the bed inside a blue privacy bag, not hooked to the bedrail, and sitting upright on a fall mat. Staff interviews, including with LVNs, CNAs, the RN, the DON, and the Administrator, confirmed that catheter bags on the floor or touching surfaces were considered an infection control concern and that facility policy required tubing and drainage bags to be kept off the floor. Despite this, the observed practices for these three residents did not comply with the facility’s catheter care and standard precautions policies, resulting in the cited infection control deficiency. Staff interviews further clarified the actions and inactions contributing to the deficiency. One LVN stated that due to the requirement to keep beds in the lowest position for fall risk residents, the catheter bags would always be touching the floor or fall mats, and initially believed this was acceptable. During the same interaction, the LVN was able to adjust two residents’ Foley bags so they were no longer touching the floor mat and were upright to prevent leakage, indicating that proper positioning was feasible but not consistently implemented. Multiple CNAs and an RN acknowledged that catheter bags should not be on the floor and identified this as an infection control issue. The DON and Administrator both stated that catheter bags were to be kept below the bladder, off the floor, and in privacy bags, and that bags on the floor represented an infection control problem, while lack of privacy bags was a dignity concern. Record review of the facility’s catheter care and standard precautions policies confirmed that tubing and drainage bags were to be kept off the floor and that appropriate infection control measures were required for each resident interaction. These observations and statements collectively demonstrate that the facility did not consistently implement its infection prevention and control program for residents with indwelling catheters.
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