Improper Positioning of Indwelling Catheter Tubing Leading to Undrained Urine
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate catheter care for a resident with an indwelling urinary catheter. Facility policy on urinary catheter care, last reviewed December 17, 2025, required that urinary drainage tubing be checked to ensure proper drainage. The resident had diagnoses including a history of stroke and bladder dysfunction, and a physician ordered an indwelling urinary catheter for urine elimination. The resident’s care plan specified that the catheter bag and tubing were to be positioned below the level of the bladder. However, observations on February 11, 2026, at 12:20 p.m. and 2:20 p.m. showed the resident in bed with the catheter tubing positioned over a wedge pillow at the resident’s side, above the bladder, with urine visibly backed up in the undrained tubing. In an interview at 2:20 p.m. the same day, the DON confirmed that the catheter tubing should have been positioned below the bladder.
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