Failure to Maintain Proper Catheter Bag Positioning and Infection Control
Penalty
Summary
The facility failed to provide appropriate catheter care for two residents with urinary catheters, as observed through multiple instances where catheter drainage bags were not properly positioned. For one resident with a history of prostate cancer and obstructive and reflux uropathy, the catheter bag was repeatedly found resting on the seat of a wheelchair next to the bed, which was lower than the seat, resulting in the bag being below the level of the bladder. This improper positioning prevented urine from draining into the bag. The resident subsequently developed blood in the urine, was diagnosed with a urinary tract infection, and was started on antibiotics. Staff interviews confirmed that catheter bags should be positioned below the bladder to ensure proper drainage and prevent complications. Another resident with diagnoses including type 2 diabetes mellitus, obstructive and reflux uropathy, and benign prostatic hyperplasia was observed on several occasions with the urinary catheter bag not placed in a dignity bag and the lower half of the collection bag lying on the floor. Staff interviews and facility policy confirmed that catheter bags and tubing should not touch the floor to prevent infection. The facility's own catheter care policies were not followed in both cases, as the drainage bags were not maintained in appropriate positions to ensure proper urine flow and infection control.