Failure to Follow Catheter Orders and Positioning Requirements
Penalty
Summary
Surveyors identified that staff did not follow physician orders and facility policies for indwelling urinary catheter management for two residents. For one resident with diagnoses including urinary retention, functional quadriplegia, benign prostatic hypertrophy, obstructive and reflux uropathy, and kidney calculi, observation during wound care showed catheter tubing with sediment draining dark yellow-orange urine and a drainage bag that yielded 1000 ml of urine when emptied, despite the CNA stating the bag had been empty at the start of the morning shift. Review of the medical record showed an active physician order for an 18 Fr Foley catheter with a 10 cc balloon and catheter care every shift, but the resident was found to have an 18 Fr catheter with a 5 cc balloon in place. Facility policies required adherence to physician orders and emptying catheter drainage bags at least every 8 hours, with accurate recording of urinary output, but the drainage bag had not been emptied by the end of the night shift as required. For another resident with quadriplegia, neurogenic bladder, functional quadriplegia, and chronic multiple wounds, surveyors twice observed the indwelling urinary catheter drainage bag attached to the upper bed railing above the resident’s waist. The LPN present acknowledged that the drainage bag should be placed below the waist to prevent backflow and then repositioned the bag. The DON later confirmed that all indwelling catheter drainage bags should be placed below the waist. The resident’s admission record and care plan included an order for an indwelling catheter size 16 Fr with a 10 ml balloon for neurogenic bladder and an intervention to position the catheter bag and tubing below the level of the bladder. The facility’s indwelling catheter policy stated that the catheter bag will always be positioned below the bladder region to prevent backflow when the Foley bag has no anti-backflow valve, but this was not followed for this resident.
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