Failure to Maintain Catheter Bag Off the Floor During Resident Ambulation
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control standards for the management of an indwelling urinary catheter for Resident #27. The resident was re-admitted with multiple diagnoses including chronic kidney disease, acute kidney failure, urinary tract infection, infection and inflammatory reaction due to other urinary catheter, obstructive and reflux uropathy, and pneumonia, and had a BIMS score of 7 indicating severe cognitive impairment. Physician orders documented enhanced barrier precautions due to a Foley catheter, catheter care every shift and as needed, and weekly changes of the catheter securement device. The care plan directed staff to position the catheter bag and tubing below the level of the bladder, away from the entrance room door, to check tubing for kinks, and to keep the drainage bag off the floor. On the survey date, the resident was observed in the hallway seated in a wheelchair and being assisted with ambulation by a PTA, with the catheter bag hanging below the wheelchair and dragging on the floor. The PTA then assisted the resident to stand and walk with the wheelchair behind, while the catheter bag continued to trail on the floor. A RN, when the issue was pointed out, stated that the bag should never touch the floor under any circumstances due to infection control concerns and adjusted the bag once the resident was seated in the dining area. The PTA acknowledged that the bag had been touching the floor and stated it should not have been. The interim DON and a CNA both stated that catheter bags are expected to be secured, hanging from the bed or wheelchair, covered with a privacy cover, properly anchored, and never allowed to touch the floor, citing infection control concerns and risk of rupture or the bag popping open. The facility’s catheter care policy, last reviewed in January 2025, specified that the collection bag must not touch the floor at any time, which was not followed in this instance.
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