Failure to Timely Empty Indwelling Urinary Catheter Bag
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have a catheter bag that was completely filled with urine. The resident required maximum assistance with toileting, had an indwelling catheter for urination, and was incontinent of bowel. The care plan specified that catheter care should be provided every shift and as needed, and physician orders required documentation of output every shift. However, there was no documented output prior to the afternoon of the day the deficiency was observed. During a morning observation, the resident was found sleeping in bed with a catheter bag containing approximately 2000 cc's of urine. An LPN confirmed the bag was full and acknowledged that catheter bags should be emptied before becoming full to prevent backflow. The DON was informed and observed the full bag at that time. This incident affected one of three residents observed for catheters, with a total of nine residents in the facility identified as having indwelling urinary catheters.