Failure to Timely Empty Urinary Catheter Bag Exceeding Labeled Capacity
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure timely drainage of a urinary catheter bag for a resident with a suprapubic urostomy and multiple medical diagnoses including hereditary spastic paraplegia, COPD, heart disease, and malignant neoplasm of the bladder. The resident, who was alert, oriented, and used a motorized wheelchair with set-up to partial assistance for ADLs, was observed in the morning with a urinary catheter bag that was round, taut, and full of yellow liquid. A CNA confirmed the bag’s appearance and, when emptying it, drained 3,000 mL of urine from the bag, despite the manufacturer’s label indicating a 2,000 mL capacity. Review of the facility’s policy on emptying urinary bags showed that catheter bags were to be emptied each shift or more often as needed to prevent the bag from becoming full, which was not followed in this instance. This deficiency represents non-compliance investigated under Complaint Number 2752534.
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