Failure to Maintain Proper Catheter Positioning During Resident Care
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate care for a resident with a suprapubic Foley catheter. During wound care, the resident's catheter drainage bag was placed on the bed rather than being hung below the level of the bladder, as required by physician orders and facility policy. This was observed while the resident, who was totally dependent on staff for all activities of daily living due to severe cognitive impairment and multiple comorbidities, was being transferred and treated for pressure ulcers. The catheter bag contained urine and was not properly positioned throughout the procedure. Interviews with the LVN and CNA involved revealed that both staff members were aware of the requirement to keep the catheter bag below the bladder to prevent backflow of urine, but failed to do so during the care episode. The facility's policy and the resident's care plan both specified the need for proper catheter positioning to prevent complications. The incident was confirmed through observation, staff interviews, and review of the resident's medical records and care plan.