Failure to Maintain Foley Catheter Drainage Bag Below Bladder During Transfer
Penalty
Summary
Staff failed to maintain proper positioning of a foley catheter drainage bag for a resident who was incontinent of bladder and required total assistance with activities of daily living. During a mechanical lift transfer, the catheter drainage bag was observed being placed above the resident's bladder, first by being hooked onto the lift sling and then placed on the resident's lap, before finally being attached to the wheelchair. This was contrary to physician orders and facility policy, both of which required the drainage bag to be kept below the level of the bladder at all times to maintain unobstructed urine flow and prevent complications. The resident involved was a severely cognitively impaired female with multiple diagnoses, including diabetes, traumatic brain injury, respiratory failure, and neurogenic bladder, and had an indwelling catheter in place. Interviews with the staff involved revealed uncertainty and lack of clear instruction regarding the correct handling of the drainage bag during mechanical lift transfers, despite documentation indicating they had been deemed competent in catheter care. The facility's policy and physician orders were not followed during the observed transfer.