Failure to Maintain Catheter Drainage Bag Below Bladder During Transfer
Penalty
Summary
A deficiency was identified when staff failed to maintain a urinary catheter drainage bag below the level of the bladder for a resident with an indwelling catheter. During a Hoyer lift transfer, the catheter drainage bag was attached to the lift arm hook at the resident's eye level, rather than being kept below the bladder as required by facility policy and the resident's care plan. Both the medication assistant and nursing assistant involved in the transfer were unsure of the correct placement for the catheter bag during the procedure. The resident involved had a history of neuromuscular dysfunction of the bladder and was dependent on staff for most activities of daily living. The care plan specifically noted the need to position the catheter bag and tubing below the bladder to prevent urinary tract infections. At the time of the incident, the resident was being treated for a urinary tract infection with antibiotics. The Director of Nursing confirmed that the catheter drainage bag should be kept below the level of the bladder, in accordance with facility policy.