Improper Urinary Catheter Drainage Bag Placement: Two residents with urinary catheters had drainage bags handled incorrectly during observation. A CNA laid one bag on the floor while emptying it, and another CNA raised a suprapubic catheter bag above bladder level, allowing urine to drain back toward the bladder. The resident care plans and staff interviews confirmed that bags were expected to remain below bladder level and not touch the floor.
A resident with reflex neuropathic bladder had a urinary catheter placed by urology for urinary retention, but the chart lacked a current order for the catheter and for catheter care. The TAR also had no documentation of catheter care, although staff later provided catheter care during observation. The DON and an LPN stated there should be documented orders for both the catheter and catheter care.
An LPN provided improper catheter and perineal care for a resident with an indwelling catheter by wiping feces toward the peri-area and catheter insertion point, using multiple swipes with the same wipe, leaving soiled wipes on the bed, and failing to secure the catheter tubing to the thigh. The facility also delayed collecting a physician-ordered UA for another resident with urinary symptoms for eight days, delaying treatment for the resident’s UTI.
Failure to Obtain Orders and Diagnoses for Urinary Catheters: The facility failed to obtain a physician order and diagnosis for urinary catheter use for two residents. One resident returned from the hospital with a catheter, and another had an order only to monitor urine output, but neither record showed a catheter diagnosis or order. Both care plans did not address the catheter use, and both residents were observed in bed with urinary catheters while stating or indicating they were unsure why the catheter was in place.
A resident with a suprapubic catheter and diagnoses including CKD and urinary retention had the catheter drainage bag observed resting on the floor while the resident was in bed. The MDS, care plan, and physician orders called for ongoing catheter care, and multiple CNAs, an RN, an LPN, nursing assistants, the DON, and the Administrator stated the drainage bag should not touch the floor.
A resident with cognitive impairment, incontinence, and neurogenic bladder used a family-applied condom catheter at night for over a month without any physician orders, care plan interventions, or documented monitoring. Surveyors observed the drainage bag and tubing on the floor, with the condom catheter secured by duct tape. A CNA reported the family applied and removed the device and managed the drainage bag, while nursing staff, including LPNs and the DON, stated they were unaware of the device’s use and that no documentation, skin assessments, or monitoring of urinary output and characteristics had been completed.
Catheter Tubing Dragging on Floor: A resident with an indwelling urinary catheter, moderate cognitive impairment, and a history of frequent UTIs was observed multiple times in a wheelchair with the catheter tubing touching and dragging on the floor in the dining room. The care plan directed staff not to let any part of the drainage system touch the floor, but staff interviews showed some CNAs did not know how to position the bag high enough under the wheelchair to prevent the tubing from dragging.
Improper urinary catheter drainage bag placement: Two residents with urinary catheters and diagnoses of obstructive and reflux uropathy were observed with drainage bags touching the floor and, at times, placed above bladder level on the bed, allowing urine to drain back toward the bladder. Staff, including CNAs, an LPN, the DON, and the Administrator, stated the bags and tubing should remain below bladder level and off the floor.
A resident with a suprapubic catheter, end stage renal disease, legal blindness, dementia, and major depressive disorder had no physician orders for catheter care, maintenance, or observation in the POS. The care plan called for monitoring for obstruction, infection, dislodgment, bowel perforation, or trauma, and for documenting urine output every shift, but the catheter bag and tubing were observed undated. An LPN, the DON, and the Administrator stated orders should have been in place for catheter care and urine monitoring.
Two residents with indwelling urinary catheters received improper catheter care and insertion services. An RN cut the balloon port instead of removing fluid properly, used nonsterile technique during insertion, cleansed the urinary opening in a circular motion rather than front to back, failed to provide peri-care, and allowed catheter tubing to develop a dependent loop with the drainage bag on the floor. For another resident, the RN dropped the sterile tray on the floor, reused it, used contaminated technique while advancing the catheter, and again used circular cleansing and improper balloon-port removal.
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