Failure to Maintain Proper Catheter Bag Position During Resident Transfer
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling Foley catheter, as observed during a transfer from wheelchair to bed. The resident, who had diagnoses including urinary tract infection, Parkinson's disease, and dementia with severe cognitive impairment, required total assistance and was transferred using a full body lift. During the transfer, staff attached the Foley catheter drainage bag to the sling at the resident's shoulder level, which was above the level of the bladder, contrary to care plan instructions and standard catheter care practices. The bag was later placed level with the bladder and then attached to the bed frame. Interviews with staff confirmed awareness that the catheter drainage bag should remain below the level of the bladder at all times to prevent urine backflow. However, staff admitted to not considering this during the transfer. The facility did not provide a policy for catheter care when requested. This failure to maintain the catheter bag below bladder level during resident transfer constituted a deficiency in providing appropriate catheter care and services.