Failure to Secure Foley Catheter Properly
Penalty
Summary
The facility failed to ensure proper care for a resident with an indwelling foley catheter, leading to the potential for catheter dislodgement, urethral trauma, and urinary tract infection. The resident, who was admitted with diagnoses including urinary retention, neuromuscular dysfunction of the bladder, and dementia, was observed without a securement device for their catheter. The securement device was found on the bathroom floor, and the resident was unaware of how it was removed. The resident required assistance with transfers due to a fall and was being helped by staff. During the survey, the LPN assigned to the resident confirmed the absence of a securement device and was unsure how it came off. The LPN disposed of the device found on the floor and obtained a new one. The Director of Nursing was informed of the situation, and it was noted that the resident's care plan was updated only after the surveyor's observation. The facility's documentation showed gaps in the treatment administration record, with several blank entries for catheter care. Interviews with staff, including a CNA and the Unit Manager, revealed a lack of clarity on how the securement device ended up on the floor and an acknowledgment of the concern regarding the absence of a securement device. The Director of Nursing was questioned about the facility's standards for foley care and the lack of prior documentation of the resident's non-compliance with the securement device. The facility's procedure for indwelling catheter care requires proper securing of the tubing to the leg, which was not adhered to in this case.