Improper Foley Catheter Bag Placement During Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) provided Foley catheter care to a female resident with a history of urinary tract infection, dementia, acute kidney failure, severe sepsis, and neuralgia. The resident had an indwelling Foley catheter as documented in her medical records and care plan, which specified that the catheter drainage bag should be kept below the level of the bladder to prevent backflow of urine. During the observed catheter care, the CNA removed the Foley bag from its proper position and placed it on the resident's bed, contrary to facility policy and standard infection control practices. The CNA later acknowledged awareness of the correct procedure and admitted that placing the Foley bag on the bed could result in urine backflow, increasing the risk of urinary tract infection. The facility's Infection Control Preventionist confirmed that the Foley bag should always remain below the bladder during care. Facility policies reviewed also emphasized the importance of maintaining the drainage bag below bladder level to discourage backflow and ensure quality of care in accordance with professional standards.