Failure to Maintain Proper Catheter Tubing Positioning
Penalty
Summary
A resident with a history of hemiplegia, hemiparesis following cerebral infarction, neuromuscular bladder dysfunction, and urinary retention was admitted with an indwelling urinary catheter. The resident was dependent on staff for all activities of daily living, including hygiene and toileting, and had documented episodes of confusion. The resident had a physician order for a urinary catheter due to retention and neurogenic bladder, and had experienced urinary tract infections (UTIs) on two separate occasions during their stay. During an observation, the resident was found lying in bed with the urinary catheter bag improperly positioned and the catheter tubing exhibiting a long dependent loop, two coils, and a kink. The tubing contained yellow liquid with white sediments. Both the Minimum Data Set Coordinator and a registered nurse confirmed that the catheter tubing should not be looped, coiled, or kinked, as this can impede urine flow and increase infection risk. Facility policy required catheter tubing to be kept free of kinks to maintain unobstructed urine flow, but this was not followed in the resident's care.