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F0690
D

Improper Positioning of Urine Collection Bag for Catheterized Resident

Houston, Texas Survey Completed on 10-30-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) failed to position the urine collection bag of an indwelling urinary catheter below the bladder of a resident after transferring the resident from bed to a recliner. The urine collection bag was observed hooked on the armrest of the recliner, which was above the resident's bladder level. This was confirmed by a licensed vocational nurse (LVN) who stated that the bag should not be at or above the bladder due to the risk of infection from potential backflow of urine. The CNA acknowledged awareness of the correct procedure but admitted to rushing and leaving the bag in the wrong position. The resident involved had chronic kidney disease, urinary retention, and was dependent on staff for most activities of daily living. The care plan included goals to prevent infection but did not specify the need to keep the urinary catheter bag below bladder level. The resident was being treated for a urinary tract infection at the time of the incident. Facility policy required that the drainage bag be positioned lower than the bladder at all times to prevent complications, including urinary tract infections.

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