Improper Management of Urinary Catheter Drainage System
Penalty
Summary
A deficiency was identified when a resident with a history of urinary tract infections (UTIs), chronic kidney disease, dementia, and urinary retention was observed with improper management of their urinary catheter drainage system. On two separate occasions, the resident was seen in the dining room sitting in a wheelchair with the urinary catheter bag and tubing lying on the floor. The catheter bag was partially full of urine, and the tubing contained yellow urine and sediment. The resident's feet were stepping on the tubing, and as the resident moved the wheelchair, the catheter bag and tubing dragged and scraped along the floor. Multiple staff members were present during these observations but did not intervene to correct the situation. The resident's medical record indicated a history of recurrent UTIs, agitation, and episodes of pulling out the catheter, requiring repeated reinsertion. The care plan included interventions to maintain a closed catheter system, keep the drainage bag below the bladder and covered, and prevent the catheter from being pulled out. Despite these documented interventions, the observations showed that the catheter system was not maintained properly, as the bag and tubing were allowed to rest on the floor, contrary to facility policy and standard infection control practices. Interviews with staff revealed a lack of awareness and inconsistent practices regarding the proper placement of the catheter bag. One CNA stated she had attached the bag to the underside of the wheelchair, as she had been taught, but was unaware that the bag had ended up on the floor. The supervisor confirmed that the catheter bag should not be on the floor and noted the resident's tendency to play with the bag and tubing. Facility policy explicitly stated that catheter tubing and drainage bags should not touch the floor to avoid infection, yet this protocol was not followed during the observed incidents.