Improper Foley and Leg Bag Care: A resident with Parkinson's disease, vascular dementia, and a neurogenic bladder was observed with catheter tubing coming out of the pant leg and a urinary drainage bag lying on the floor, with cloudy contents in the tubing and no place to hang the bag. Although the care plan and staff believed the resident handled their own leg bag changes, the DON stated staff should apply the leg bag and not expect the resident to do it themselves for infection control reasons.
A resident with quadriplegia, chronic kidney disease, and a history of UTIs had an indwelling Foley catheter and a care plan directing staff to keep the drainage bag below bladder level, provide catheter care each shift, and monitor and document output. Surveyors repeatedly observed the urine drainage bag, containing a large volume of amber urine with white mucus, lying directly on the floor while an LPN entered the room to administer medications and feed the resident without correcting the bag’s position. Later, despite posted enhanced barrier precautions and available supplies, a CNA wearing only gloves placed a urinal directly on the floor, emptied approximately 1,800 mL from the drainage bag while intermittently placing both the bag and urinal on the floor, left the spigot open on the floor during the process, and failed to clean the spigot tip with alcohol, contrary to facility policy and expected infection control practices.
Two residents with indwelling urinary catheters did not receive appropriate catheter management. One resident had failed voiding trials, no documented urology follow-up, and a later voiding trial that failed without documented provider notification or a clear plan. Another resident with a history of bladder infections reportedly wore a leg bag to bed, with staff and the resident giving conflicting accounts about bag changes and no documented education or declination.
A resident with a chronic Foley catheter had the drainage bag stored above waist level on a wheelchair arm pad during observation. An LPN did not recognize the improper placement, and RN staff, the DON, and the Medical Director stated the bag should be kept below bladder level for proper drainage; they noted that placing it above that level can prevent drainage and cause urinary retention and infection.
A resident with CHF, CKD, and acute cystitis was observed with an indwelling urinary catheter despite no documented physician order, indication, or care plan. The chart and staff interviews confirmed the catheter was present, but there were no orders for size, balloon size, reason for use, or catheter care instructions in the care plan or Kardex.
Foley Catheter Lacked Indication and Proper Care A resident admitted with a Foley catheter had no documented clinical justification for continued use and no documented voiding trial, despite baseline incontinence and a hospital note stating the catheter should be removed once the resident was more ambulatory. Staff observations showed the drainage bag and tubing repeatedly on the floor, the catheter not secured to the resident, and the bag disconnected and then reconnected before being placed back on the floor. Interviews with the DON, ADON/IP, LPN, CNA, and NP confirmed the lack of clear documentation for the catheter and that the bag should not touch the floor and should be secured properly.
A resident with severe cognitive impairment had a Foley catheter documented in the chart without a clear physician order, clear insertion date, or documented trial of void when first admitted with the catheter. After readmission, the record again lacked an order and insertion documentation while Foley care and catheter changes continued, and nursing leadership acknowledged the care plan and catheter documentation were incomplete.
A resident with a history of urinary incontinence and other medical conditions was provided with an indwelling urinary catheter at their request, despite no documented clinical indication. Staff proceeded with the insertion based on the resident's wishes and a physician's note, but failed to document any education about the risks or clinical implications of catheter use, and the order lacked details such as catheter size. Facility policy required both a valid clinical reason and resident education prior to catheter insertion, neither of which were met in this case.
A resident with an indwelling Foley catheter did not receive documented daily catheter care over several months, as required by facility policy to prevent urinary tract infections. Despite staff statements that catheter care should be performed and documented, there was no physician order for daily care until late in the review period and no evidence in nursing progress notes that the care was provided. This deficiency was identified through record review and staff interviews.
A resident with occasional urinary and bowel incontinence was not provided with a toileting program or individualized continence care, despite having intact cognition and expressing a preference to use the toilet rather than wear adult briefs. Staff did not update the care plan or trial a toileting program, and the resident's incontinence episodes increased. Interviews revealed that the resident was capable of being toileted with assistance, but staff cited insufficient staffing and did not implement appropriate interventions.
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