Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident who was dependent on staff for all activities of daily living and had multiple complex medical conditions, including chronic respiratory failure, chronic encephalopathy, tracheostomy, cerebral palsy, and seizure disorder, was observed with a deficiency in urinary catheter care. The resident's care plan specifically required staff to ensure that the urinary catheter tubing was not kinked and that urine could flow freely at all times to prevent infection. During an observation, the resident was found in bed with the urinary catheter tubing hanging below the bed and forming a large loop, which contained yellow liquid with sediment. A registered nurse confirmed that the tubing was looped and that urine was not draining properly, acknowledging that the tubing should be straight to allow for proper drainage. Review of the facility's catheter care policy also indicated the need to keep tubing free of kinks and obstructions. This failure to maintain proper catheter tubing positioning constituted a deficiency in providing appropriate care to prevent urinary tract infections.