Improper Positioning of Urinary Catheter Drainage Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed lying in bed with the catheter drainage bag anchored to the side rail above the resident's head, rather than below the level of the bladder. This placement was confirmed by a Registered Nurse (RN) Supervisor, who acknowledged that the drainage bag should be positioned lower than the bladder to facilitate proper urine flow. The RN Supervisor adjusted the drainage bag after the issue was pointed out. Interviews with nursing staff and the Director of Nursing confirmed that facility protocol and policy require the drainage bag to be kept below the bladder to prevent backflow and potential infection. The resident involved had a medical history including benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, obstructive uropathy, and a pressure ulcer. Physician orders and the care plan specified the need for indwelling catheter care every shift and interventions to prevent infection, including proper anchoring of the catheter. Facility policy also outlined the importance of maintaining the drainage bag below bladder level as part of infection prevention. The failure to position the drainage bag correctly constituted a lapse in following established protocols and care plans for catheter management.