F0690

D

Failure to Maintain Urinary Catheter Drainage Bags Off the Floor

Dillsboro, Indiana Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to follow infection control guidelines for urinary catheters for two residents with indwelling catheters who had recent UTIs. For one resident with severe cognitive impairment, neurogenic bladder, and dependence on staff for care, multiple observations over several days showed the urinary catheter drainage bag, equipped with a dignity flap, lying on or touching the floor while the resident sat in a recliner in the dementia unit common area. On each occasion, there was no dignity bag covering the catheter bag. The resident’s clinical record documented an indwelling urinary catheter and recent treatment for UTIs, including new antibiotic orders on several dates related to a UTI, foul-smelling urine, and cellulitis.

For another resident with upper and lower extremity impairments who was dependent on staff for care and reported having a recent UTI, surveyors observed the urinary catheter drainage bag, also with a dignity flap, hanging under the wheelchair with portions of the bag touching the floor in the resident’s room and in the dining room on multiple occasions. There was no dignity bag covering the catheter bag during these observations. Facility staff, including an LPN, a QMA, and the ADON, acknowledged during interviews that residents’ urinary catheter drainage bags should not touch the floor. The facility’s written policy on indwelling Foley catheter care stated that the main purpose of proper catheter care is to prevent catheter-associated UTIs.