Failure to Properly Position Catheter Bag Below Bladder Level
Penalty
Summary
Staff failed to properly secure and position a resident's catheter bag below the level of the bladder, as required by facility policy and the resident's care plan. The resident, who had a history of renal insufficiency, obstructive uropathy, diabetes, and a suprapubic catheter, was observed on multiple occasions with the catheter bag either lying on the floor under the wheelchair or hung above the level of the bladder. These observations were made during routine checks and included instances where the catheter bag contained yellow urine and was not properly secured, as well as when the resident reported difficulty accessing the call light due to running over the catheter tubing with the wheelchair. Further review of the clinical record and staff interviews confirmed that the facility's policy required the catheter bag to be kept below the level of the bladder at all times to ensure proper drainage and minimize infection risk. The Director of Nursing acknowledged that the catheter bag should be positioned below the bladder. The care plan for the resident specifically directed staff to maintain this positioning, but staff failed to consistently follow these instructions, as evidenced by the surveyor's observations.