Failure to Provide Adequate Catheter Care and Proper Bag Positioning
Penalty
Summary
Staff failed to provide adequate catheter care and proper positioning of a urinary catheter bag for a resident with an indwelling catheter. The resident, who had impaired cognition and required maximum assistance with toileting, was observed on multiple occasions with the catheter bag improperly placed—once in the resident's lap and on two separate occasions on the floor under the bed. The catheter tubing was noted to contain a large amount of thick sediment, and the insertion site and tubing had black dried debris around them. The resident was unable to recall when care was last provided, and a CNA confirmed that catheter care had not been performed since the start of her shift. Review of the resident's care plan and physician orders indicated that catheter care was to be provided every shift and as needed, and facility policy required that catheter bags be kept off the floor and positioned lower than the bladder. Despite these directives, observations and staff interviews confirmed that these standards were not met, resulting in inadequate catheter care and improper catheter bag positioning for the resident.