Improper Maintenance of Urinary Catheter Collection Bag
Penalty
Summary
A deficiency was identified when a resident's urinary catheter collection bag was observed on the floor beside the bed while the resident was lying in bed. Staff interviews confirmed that the collection bag was intentionally left on the floor at the request of the resident's family due to the resident's confusion. However, both the Divisional Director of Clinical Services and a Registered Nurse confirmed that the catheter collection bag should not be placed on the floor, as this is inconsistent with facility policy. Further observation showed that the same resident's catheter collection bag was later found hanging from the back of a wheelchair at shoulder level, which is above bladder level. A Licensed Practical Nurse confirmed this improper positioning. Review of the facility's catheter care policy indicated that the collection bag should not be on the floor and must be secured to allow for proper drainage and prevent urine reflux. The resident involved had multiple diagnoses, including type two diabetes mellitus, hypertension, hyperlipidemia, atrial fibrillation, and malnutrition.