Improper Positioning of Catheter Bags and Tubing
Penalty
Summary
The facility failed to provide adequate care and services to prevent injuries for two residents who were observed with their catheter bags and tubing improperly positioned. Resident #123 was seen with her catheter bag and tubing dragging on the floor while she was seated in her wheelchair, posing a potential risk for accidents and infection. The resident's medical records indicated she had a history of retention and was using a catheter, which was supposed to be positioned off the floor according to her care plan. However, the nursing staff, including Staff E, RN, were unaware of the improper positioning of the catheter bag and tubing. Similarly, Resident #124 was observed with her catheter bag and tubing touching the floor on multiple occasions. The tubing was seen in excess tension and was even run over by the wheelchair tires when a visitor repositioned the resident. Resident #124's medical records showed a history of retention and the use of a catheter, with care plans specifying the need for proper positioning of the catheter bag and tubing. Despite these care plans, the staff, including CNAs Staff F and G, confirmed they had observed the improper positioning but did not consistently address it. Interviews with the Director and the Director of Nursing revealed that they were not aware of the issues with the catheter bags and tubing touching the floor. The facility's policy on catheter care emphasized the importance of securing the tubing and positioning the drainage bag off the floor, yet this was not adhered to in practice. The failure to follow these procedures led to the deficiency in providing adequate and appropriate health care to the residents involved.
Plan Of Correction
On the for resident #123 was positioned and secured properly so the bag nor the tubing touched the floor. On the for resident #124 was positioned and secured properly so the bag nor the tubing touched the floor. On , all other residents identified with were checked for proper positioning and securing so the bag nor the tubing of the touched the floor. For these other residents, no area of concern identified. On the Director of Nursing (DON)/designee initiated education for nurses, certified nursing assistants and staff related to proper positioning and securing of bags/tubing. Education completed by The Director of Nursing/designee for all residents with will do an audit 2 times a week for 12 weeks to ensure proper positioning and securing the tubing for those residents with so no bag or tubing for are touching the floor. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.