Improper Positioning of Urinary Drainage Bags
Penalty
Summary
The facility failed to properly position urinary drainage bags for two residents, resulting in inadequate drainage and the potential for urine to flow back toward the bladder. For one resident with multiple sclerosis, hemiplegia, and neuromuscular bladder dysfunction, observations revealed the urinary drainage bag was placed flat on a stretcher and later on the floor, with urine backing up in the tubing and a strong urine odor present. The drainage port was also found to be improperly clamped, leading to urine spillage on the floor. The resident was dependent on staff for all activities of daily living and required an indwelling catheter. Another resident with cerebral infarction, hemiplegia, and chronic kidney disease, who was also dependent on staff for all ADLs and used an external catheter, was observed with the urinary drainage bag resting on the floor. The drainage bag remained in this position during subsequent observations, and the tubing was not adjusted to promote adequate urinary drainage. These actions were inconsistent with the facility's urinary catheter care policy, which requires drainage bags to be positioned below the bladder and off the floor to prevent backflow and potential infection.