Failure to Keep Indwelling Catheter Drainage Bag Off the Floor
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter drainage bag for one resident, resulting in the bag resting on the floor on multiple occasions. The resident had an indwelling urinary catheter and a history of urinary tract infection, as documented in a care plan reviewed on 01/05/26. On 01/05/26 at 8:58 AM, the resident was observed in bed with the indwelling urinary drainage bag positioned at the side of the bed, with the bottom portion of the bag resting on the floor. On 01/06/26 at 8:38 AM, the resident was again observed in bed with the drainage bag not hanging from any support and lying flat on the floor, while the wheels of the bedside table were running over the drainage bag. During an interview on 01/06/26 at 11:04 AM, a CNA stated that staff provided all indwelling urinary catheter care and management for the resident and acknowledged that a drainage bag should not touch the floor to prevent contamination or infection. The facility’s Indwelling Catheter Care and Maintenance policy, reviewed in 03/2025, directed staff to keep the drainage bag off the floor. These observations and statements show that staff did not follow the facility’s catheter care policy or accepted practices for maintaining the drainage bag off the floor for this resident with an indwelling urinary catheter and a history of urinary tract infection.
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