Failure to Maintain Catheter Tubing Off the Floor
Penalty
Summary
Staff failed to provide proper urinary catheter care for a resident with a history of cerebral infarction, neuromuscular bladder dysfunction, and an infection related to an indwelling urinary catheter. The resident's care plan required staff to change the catheter as ordered, check for patency and urinary output every shift, observe for pain or discomfort, ensure the catheter tubing was free of kinks, and keep the catheter bag and tubing below the level of the bladder and off the floor. The facility's policy also directed staff to keep the catheter tubing and drainage bag off the floor. Despite these directives, observations on two separate occasions found that the resident's catheter tubing was resting on the floor while the resident was seated in a wheelchair in the dining room. On one occasion, approximately four inches of tubing were on the floor, and on another, about one inch was on the floor. An administrative nurse confirmed that staff were expected to prevent tubing from resting or dragging on the floor, indicating a failure to follow established protocols for catheter care.