Failure to Maintain Proper Urinary Catheter Positioning and Drainage
Penalty
Summary
Facility staff failed to ensure proper urinary catheter care for two residents with indwelling catheters, resulting in catheter tubing being observed with dependent loops and backflow of urine. For one resident with Alzheimer’s disease, aphasia, and neuromuscular bladder dysfunction, the catheter tubing was found hanging below the bed with a large dependent loop containing yellow liquid and sediment that back flowed toward the urine drainage port. Staff interviews confirmed that the tubing was not straight and that urine was not draining properly into the collection bag. A second resident, diagnosed with hypertension, hyperlipidemia, depression, neuromuscular bladder dysfunction, and a history of urinary tract infection, was also observed with a dependent loop in the catheter tubing. Staff, including an LVN and RN, acknowledged that the tubing was not straight, urine was present in the loop, and urine was not able to drain into the collection bag. Both staff members stated that dependent loops or kinks could prevent proper drainage and potentially cause urine to backflow into the resident. The facility’s policy and procedure for urinary catheter care, reviewed by surveyors, required staff to maintain unobstructed urine flow and to check frequently that residents were not lying on the catheter and that tubing was free of kinks. Despite this policy, observations and staff interviews confirmed that the required practices were not followed for both residents, resulting in improper catheter positioning and urine backflow.