Failure to Position Catheter Drainage Bag Below Bladder
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was not provided appropriate catheter care as required by facility policy and standard nursing procedures. The resident, who had diagnoses including hemiplegia, hemiparesis, and urinary retention, had a physician's order for an indwelling catheter and a care plan specifying that the drainage bag should be positioned below the level of the bladder. Multiple surveyor observations found that the drainage bag was not visible while the resident was in bed, and upon further inspection, it was discovered that the bag was attached to the resident's leg and lying perpendicular, not below the bladder as required. Staff interviews confirmed that the drainage bag was not positioned according to the care plan and standard procedures. Both a nursing assistant and a registered nurse acknowledged that the bag was not below the bladder, and the Director of Nursing Services stated that her expectation was for the drainage bag to be placed below the bladder. These findings demonstrate that the facility failed to provide appropriate catheter care for the resident, as required by both the care plan and established nursing guidelines.