Improper Placement of Drainage Bag in Resident's Care
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare and treatment services for a resident, as evidenced by the improper placement of a drainage bag. During an observation, the drainage bag was found anchored to the side rail above the resident, increasing the risk of dislodgement. A Registered Nurse (RN) Supervisor confirmed that the drainage bag should be positioned lower than the resident to facilitate proper flow and prevent complications. The RN Supervisor adjusted the drainage bag to the correct position after being informed of the issue. The resident involved had a diagnosis that included hyperplasia with lower tract symptoms and was at increased risk due to retention. The care plan for the resident included maintaining the anchoring device to prevent dislodgement and monitoring the site for skin integrity. The facility's policy stated that the drainage bag should be kept as a closed system and positioned lower than the resident to allow drainage by gravity. Despite these guidelines, the improper placement of the drainage bag was observed, indicating a failure to adhere to established protocols.
Plan Of Correction
Immediate Action: Drainage bag for affected sample resident #184 was immediately repositioned below level of the to prevent. Care plan reviewed for accuracy. Identification of Residents with potential to be affected: All residents with using a drainage system, have potential to be affected. System Changes: Control Policy was reviewed for accuracy. All licensed Nursing staff were educated and trained by the Control Preventionist, Director of Nursing, and the Assistant Director of Nursing in care with emphasis on proper placement of Drainage appliance/bag. They were required to demonstrate return demonstration on proper placement on drainage appliance/bag. Monitoring: