Deficiencies in Catheter Management and Resident Dignity
Penalty
Summary
The facility failed to ensure that physician orders for urinary catheters included necessary details such as the size of the suprapubic catheter, balloon sizing, and the amount of fluid needed for balloon inflation for three residents. This omission was confirmed through staff interviews and a review of clinical records. Specifically, the orders for Residents R53, R58, and R316 lacked these critical details, which are essential for proper catheter management and resident care. Additionally, the facility did not adhere to its policy on maintaining resident dignity by failing to cover catheter bags as required. Observations revealed that the catheter drainage bags for Residents R58 and R316 were not covered with dignity bags and were positioned facing the door entrance, contrary to the facility's dignity policy. This was confirmed by interviews with registered nurses who acknowledged the oversight. The deficiencies were identified during a review of facility policies, clinical records, and staff interviews. The Director of Nursing confirmed the facility's failure to include necessary catheter details in physician orders and to ensure catheter bags were covered, impacting the care and dignity of the residents involved.
Plan Of Correction
The size of the suprapubic catheter, the balloon size and the proper fluid amount were obtained for residents R53, R58, and R316. Also, the catheter drainage bags were covered for residents R58 and R316. RNs, and LPNs, will be educated by the Director of Nursing, In-Service Director and/or designee on adding the size of the suprapubic catheter, the balloon size and the proper fluid amount urinary catheter type and size when entering a suprapubic order. RNs, and LPNs, and CNAs will be educated by the Director of Nursing, In-Service Director and/or designee on covering all the urinary drainage bags with dignity bags. An audit of all residents with a suprapubic catheter will be conducted by the Director of Nursing or designee to ensure the order contains the size of the catheter, the balloon size and the fluid requirements weekly for three weeks and then biweekly for three weeks. An audit of all residents with a foley will be conducted by the Director of Nursing or designee to ensure that their catheter drainage bags are covered will be conducted weekly for three weeks and then biweekly for three weeks. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.