Failure to Maintain Proper Positioning of Catheter Drainage Bags
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the management of indwelling urinary catheter drainage bags for two residents. One resident was observed on multiple occasions lying in bed with a catheter bag that was 100% on the floor and not attached to the bed, despite a care plan intervention dated 9/11/2025 specifying that tubing or any part of the drainage system should not touch the floor. Another resident was repeatedly observed in bed with a catheter bag hanging from the bed but with the bottom of the bag resting on the floor, including after the bag had been moved and attached to a different part of the bed. In interviews, the Infection Control Preventionist stated that catheter bags should always hang on the side of the bed, below the resident and not touching the ground, and the DON confirmed that catheter bags should not be on or hanging on the floor and that this was an infection control concern. These observations and interviews demonstrate that staff did not consistently follow established infection control practices and the resident’s care plan interventions regarding proper positioning of catheter drainage bags, resulting in catheter systems resting on the floor for two of three residents reviewed with catheters.
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