F0690

D

Failure to Follow Facility Procedure for Cleaning Urinary Drainage Tubing

Brookville, Ohio Survey Completed on 03-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate urinary catheter care in accordance with its own policy and skills checklist. A resident with neuromuscular dysfunction of the bladder, intact cognition, and dependence on staff for toileting, transfers, and bed mobility was admitted with an indwelling urinary catheter. The resident’s care plan specified catheter care every shift, changing the catheter bag as needed, and changing the catheter per physician orders. The quarterly MDS documented ongoing urinary catheter use.

During an observation, a CNA performed catheter care and then proceeded to empty the resident’s urinary drainage bag into a urinal after performing hand hygiene and donning gloves. After draining the bag, the CNA reinserted the tip of the drainage tubing back into the storage sleeve on the urinary drainage bag without using an alcohol pad to clean the end of the tubing. In a subsequent interview, the CNA acknowledged not using an alcohol pad, and an RN confirmed that staff should clean the end of the drainage tubing with an alcohol pad before reinserting it into the storage sleeve. Review of the facility’s catheter care and urinary output measurement skills checklist from 2009 showed that staff were required to close the drainage outlet, wipe it with an alcohol pad, and then reinsert it into the catheter bag without contaminating it. This failure was identified as an incidental finding during a complaint investigation.