Failure to Maintain Proper Positioning of Indwelling Urinary Catheter Bags
Penalty
Summary
The facility failed to ensure proper care and handling of indwelling urinary catheter bags for two residents. In the first instance, a resident with an indwelling urinary catheter was being transferred from bed to a shower chair using a mechanical lift. During the transfer, two CNAs attached the catheter bag to the sling strap of the lift, positioning it above the resident's bladder. This resulted in visible backflow of cloudy yellow urine into the resident's bladder. The resident's care plan and the facility's urinary catheter care policy both specify that catheter bags should be kept below the level of the bladder at all times to prevent backflow. In the second instance, another resident's indwelling urinary catheter bag was observed lying on the floor next to the bed while the resident was in bed. The bag remained on the floor during and after a wound care procedure performed by a wound care nurse and nurse practitioner, and was still on the floor later that morning. The facility's catheter care policy states that catheter bags should be kept off the floor. These observations were confirmed by the DON, who acknowledged that the catheter bags were not handled according to policy.