Failure to Maintain Proper Positioning of Indwelling Catheter Bag and Tubing
Penalty
Summary
A deficiency was identified when a resident with a history of neurogenic bladder, scoliosis, and intestinal-genital tract fistulae, who utilized an indwelling suprapubic catheter, was repeatedly observed with their catheter bag and tubing resting on the floor. Multiple observations documented the catheter bag and tubing either on the floor or dragging as the resident self-propelled their wheelchair, both in the resident's room and in the hallway. Staff present during these incidents did not intervene to correct the position of the catheter bag and tubing. Interviews with nursing staff revealed inconsistent responses regarding the appropriate action when a catheter bag or tubing is found on the floor. Some staff indicated the bag should be replaced, while others stated it should be wiped off and repositioned. The facility's policy directs that catheter tubing should not be positioned above the bladder and that the drainage bag should be kept off the floor and in a dignity bag. Despite these guidelines, the observed failure to maintain the catheter bag and tubing in the correct position led to the deficiency.