Catheter Bag Improperly Positioned Above Bladder Level
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, dementia, and a stage IV pressure injury was observed with an indwelling urinary catheter bag positioned above the level of her bladder. During wound care provided by an LPN and a Unit Manager/RN, the resident was in bed with her feet elevated, and the catheter drainage bag was attached to the footboard, even with her feet and above her bladder. The drainage tubing was on the bed, and during repositioning, urine was seen flowing back toward the resident and away from the bag. After the wound care was completed, the staff exited the room without repositioning the catheter bag and tubing below the bladder level. Interview with the LPN confirmed that the catheter bag was incorrectly placed and acknowledged that it should have been hanging lower, off the bed frame, to prevent backflow. The resident's care plan specifically directed that the catheter bag and tubing be positioned below the level of the bladder, and the facility's catheter care policy also required this practice to discourage backflow of urine. The failure to follow these protocols resulted in the identified deficiency.