Improper Catheter Bag Positioning During Resident Transfer
Penalty
Summary
A deficiency occurred when a resident with an indwelling suprapubic urinary catheter did not receive appropriate catheter care during a transfer from bed to Geri-chair. During the transfer, CNA C placed the catheter drainage bag flat on the foot of the bed, which was above the resident's bladder level, and later hung the bag on the shaft of the mechanical lift. This positioning allowed urine to flow back toward the resident's bladder. The resident required extensive assistance with mobility and had a history of obstructive uropathy and cancer, with moderately impaired cognition. Interviews with CNA C, the Administrator, and the DON confirmed that staff were trained and expected to keep the catheter drainage bag below the bladder to prevent backflow and potential infection. However, the facility's policy on catheter care did not address this specific concern. The failure to maintain the drainage bag below bladder level during the transfer was observed directly and acknowledged by staff as contrary to proper procedure.