Improper Catheter Care and Drainage Bag Positioning
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. During hygiene and catheter care, an LPN placed the resident's urinary drainage bag and tubing on the bed next to the resident's feet, at the same level as the bladder, resulting in backflow of urine in the tubing. The LPN later lowered the drainage bag and emptied the urine without cleaning the port before or after the procedure. The resident had a history of hemiplegia and hemiparesis following a cerebral infarction and was noted to have severe cognitive impairment. Physician orders specified that the urine collection bag should always be kept below the level of the bladder. Interviews with staff, including the LPN, Infection Control Preventionist, and DON, confirmed that the drainage bag should be kept below the bladder to facilitate urine flow and prevent backflow. The LPN acknowledged that leaving the bag on the bed could cause reflux and that the port should be cleaned with an alcohol pad before and after draining urine. The Infection Control Preventionist and DON both stated that the bag should not touch the floor and must hang by gravity, and that the exit port should be cleaned with soap and water. It was also revealed that there was no facility policy regarding the correct positioning of the indwelling urinary catheter drainage bag.