Deficiency in Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with a catheter, as evidenced by observations of the tubing being kinked and touching the floor. During the survey, Resident #2 was observed in bed with oxygen in progress at 2 liters per minute via a nasal cannula, and no apparent distress was noted. However, the catheter tubing was observed to be kinked in a circle and not properly draining. A Registered Nurse (RN) present in the room was notified by the surveyor about the kinking of the tubing, and the RN then straightened out the tubing to allow free flow. The RN stated that they round every morning to check the tubing, but on this occasion, they did not notice it was kinked. Further observations revealed that the catheter tubing was touching the floor. A Licensed Practical Nurse (LPN) stated that the tubing was not touching the floor during their rounds and suggested that the bed being lowered too low might have caused the tubing to touch the floor. The LPN rounds every two hours and communicates with the Certified Nursing Assistant (CNA) about required interventions for care. The CNA confirmed receiving in-services on catheter care and stated that they ensure the collection bag does not touch the floor and is anchored to the bed. Despite these measures, the tubing was found touching the ground, indicating a lapse in maintaining proper catheter care. The Director of Nursing (DON) was made aware of the concerns and stated that staff are to monitor the catheter to ensure it is draining properly and that the tubing is not kinked or touching the floor. The physician orders for Resident #2's care were found to be outdated, as they did not reflect the current catheter in use. The facility's policy on catheter care emphasizes securing and checking drainage tubing and bags to prevent urinary tract infections, but the observations during the survey indicated non-compliance with these procedures.
Plan Of Correction
Identify patients that were at risk and what did: Regarding Resident #2, the drainage tubing was immediately changed, and the bed was raised. The assigned Nurse and C.N.A were immediately in-serviced on control protocol and the difference between Super pubic and regular. Identify patients that were at risk and what did: A 100% audit was completed to identify residents with care and/or to ensure bags are not kinked and not touching the floor. All nurses and CNAs were educated on control protocol and the difference between Super pubic and regular. Measures put in Place: A clinical in-service was held for all nursing staff to discuss care and control protocol. How will you monitor: The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with safety as far as positioning and ensuring that it is not touching the floor. Additionally, the supervisor form will be handed to the DON for compliance tracking. The DON created a care random audit observations checklist. The random audit will be done daily. Continuous in-service on the care of residents with super pubic and needed will be done monthly and as needed.