Failure to Maintain Catheter Tubing Off the Floor for a Catheterized Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident with an indwelling urinary catheter. The resident, an older female with urinary retention, had an MDS assessment and care plan identifying the presence of an indwelling urinary catheter, with care plan interventions that included ensuring a privacy bag and leg strap or anchor were in place. Physician’s orders directed staff to check the Foley catheter tubing secure device placement every shift and allowed use of a leg strap to secure the Foley catheter. Despite these orders and the facility’s urinary catheter care policy, which required that catheter tubing and drainage bags be kept off the floor, the resident’s catheter tubing was observed touching the floor while she was seated in her wheelchair in the hallway. During the observation, a LVN confirmed that the catheter tubing was on the floor and stated that it should have been attached to a clip under the wheelchair to prevent this. The LVN attempted to locate the clip but was unable to find it and did not know why it was not present. The LVN acknowledged that catheter tubing on the floor posed potential infection control issues. The DON, after being informed of the situation, also confirmed that the catheter tubing should have been attached to a clip under the wheelchair and acknowledged the infection control concerns associated with the tubing being on the floor. These observations and interviews demonstrated that the facility did not follow its own catheter care policy and physician’s orders regarding keeping catheter tubing off the floor.
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