Inadequate Catheter Care Leads to Safety Hazards
Penalty
Summary
The facility failed to provide adequate care and services to prevent injuries for two residents who utilized urinary catheters. Observations revealed that Resident #123 had a catheter bag and tubing hanging below the seat of her wheelchair, with portions touching the floor. This was observed while she was scooting back and forth in her wheelchair, creating a potential hazard. The resident's medical records indicated a diagnosis of urinary retention, and she had orders for a catheter. However, the care plan did not ensure the catheter bag and tubing were kept off the floor, as confirmed by the resident's nurse, Staff E, RN. Similarly, Resident #124 was observed with a catheter bag and tubing touching the floor while seated in her wheelchair. The tubing was in excess tension and was observed touching the front wheel of the wheelchair. The resident's medical records showed a history of urinary retention and orders for a catheter. Despite this, the care plan failed to ensure the catheter bag and tubing were properly positioned, as confirmed by Staff E, RN, and CNAs Staff F and Staff G. Both CNAs acknowledged observing the catheter equipment on the floor and stated that they could reposition it or report it to a nurse. The facility's Director of Nursing provided a policy for catheter care, which stated that the drainage bag should be secured in a manner that prevents it from touching the floor. However, the policy was not effectively implemented, as evidenced by the observations of the catheter bags and tubing on the floor for both residents. The Director of Rehabilitation also confirmed that her staff should ensure proper positioning of the catheter equipment but was unaware of the deficiencies observed with Residents #123 and #124.
Plan Of Correction
On the for resident #123 was positioned and secured properly so the bag nor the tubing touched the floor. On the for resident #124 was positioned and secured properly so the bag nor the tubing touched the floor. On all other residents identified with were checked for proper positioning and securing so the bag nor the tubing of the touched the floor. For these other residents, no area of concern identified. On the Director of Nursing (DON)/designee initiated education for nurses, certified nursing assistants and staff related to proper positioning and securing of bags/tubing. Education completed by The Director of Nursing/designee for all residents with will do an audit 2 times a week for 12 weeks to ensure proper positioning and securing the tubing for those residents with so no bag or tubing for are touching the floor. The Director of Nursing/designee will review the audits with the monthly Quality Assurance Performance Improvement (QAPI) Committee for three months. The Quality Assurance Performance Improvement committee will evaluate the outcome of the audits and if necessary, amend the improvement plan and continue to monitor until substantial compliance has been determined by the committee.