The December 22 incident at Aperion Care Dolton involved a resident with a tracheostomy who had been hospitalized for a urinary tract infection just two months earlier. When asked why the drainage bag shouldn't touch the floor, the registered nurse caring for the patient said she didn't know how to prevent it.
Federal inspectors observed the violation during a complaint investigation on December 29. The resident, identified as R3 in the inspection report, was lying in bed at 11:30 a.m. with the catheter drainage bag resting on the floor and no privacy covering. The bag remained visible to anyone walking down the hallway.
Fifteen minutes later, inspectors returned to find the drainage bag still in the same position. The registered nurse responsible for the resident's care, identified as V3, was questioned about the improper positioning.
"R3's bed is in a low position, and she did not know how to prevent the drainage bag from touching the floor," according to the inspection report. The nurse acknowledged that the resident could understand questions and respond with yes or no answers.
The Director of Nursing, notified at 11:55 a.m., immediately recognized the violations. She told inspectors that urinary drainage bags should never touch the floor to prevent contamination and should be covered with privacy bags to protect resident dignity.
The resident had been admitted to Aperion Care Dolton on August 20 with multiple serious conditions including quadriplegia, neuromuscular dysfunction of the bladder, and tracheostomy status. Seven weeks later, on October 7, the facility sent the resident to the hospital with a urinary tract infection diagnosis.
Medical records show the resident's catheter was placed due to pressure injuries. The care plan from November 10 stated the goal was keeping the resident "free from catheter related trauma" and included monitoring for signs and symptoms of urinary tract infections.
The facility's own policy, last revised in February 2019, specifically addresses the issue observed by inspectors. The policy states that "urinary drainage bag and tubing shall be positioned to prevent either from touching the floor directly." It recommends placing drainage bags in secondary vinyl bags or similar devices to prevent contact with floors or other surfaces.
Despite having clear written protocols, the registered nurse demonstrated a fundamental lack of knowledge about catheter care infection control measures. The Director of Nursing later told inspectors that V3 and other staff members received in-service training on indwelling urinary catheter care following the incident.
Catheter-associated urinary tract infections represent one of the most common healthcare-associated infections in nursing homes. Proper positioning of drainage bags prevents bacteria from the floor from traveling up the tubing and into the bladder, a basic principle of infection control.
The violation occurred in a resident who had already experienced one urinary tract infection requiring hospitalization. Federal regulations require nursing homes to provide appropriate catheter care and take measures to prevent urinary tract infections, particularly for vulnerable residents with complex medical conditions.
The inspection found that Aperion Care Dolton failed to ensure proper catheter drainage bag positioning for one of two residents reviewed for indwelling urinary catheter care. The facility received a citation for minimal harm with potential for actual harm affecting few residents.
The resident's exposure extended beyond medical risk to dignity concerns. With the drainage bag visible to anyone passing in the hallway and no privacy covering in place, the violation compromised both infection control standards and basic respect for the resident's privacy.
The incident highlights gaps in staff training and supervision at the facility. When a registered nurse doesn't understand fundamental infection control principles for catheter care, it raises questions about the adequacy of ongoing education and competency verification for nursing staff.
For the quadriplegic resident with tracheostomy and history of urinary tract infection, proper catheter care represents a critical component of medical treatment. The failure to maintain basic positioning standards potentially exposed an already vulnerable patient to additional health risks.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aperion Care Dolton from 2025-12-29 including all violations, facility responses, and corrective action plans.