Improper Catheter Drainage Bag Positioning
Penalty
Summary
The facility failed to ensure proper management of an indwelling urinary catheter for a resident with severe cognitive impairment, multiple sclerosis, neurogenic bladder, and a history of recurrent urinary tract infections. The resident was dependent on staff for all activities of daily living and had a care plan specifying that the catheter drainage bag should be kept below the bladder level, the tubing should be free of kinks, and the catheter should be secured to avoid tension. The care plan also required staff to monitor for signs and symptoms of infection and to follow specific protocols for catheter and drainage bag care. Despite these interventions, observations revealed that the resident's catheter drainage bag was repeatedly found hanging on the armrest of the wheelchair at a level equal to the resident's pelvis, rather than below the bladder as required. Interviews with nursing assistants indicated inconsistent practices, with some staff placing the bag on the side or under the wheelchair, and others clipping it to prevent dragging. The medical director and DON both confirmed that the drainage bag should be kept below bladder level to ensure proper drainage and prevent urine reflux. Facility policy also required the drainage bag to be kept below the bladder to reduce the risk of catheter-associated urinary tract infection.