Failure to Secure Indwelling Urinary Catheter as Required by Care Plan
Penalty
Summary
The facility failed to follow its policy and care plan interventions for urinary catheter care for a resident with multiple diagnoses, including neurogenic bladder and chronic kidney disease. The resident had an indwelling urinary catheter, and the care plan specified that the catheter should be secured to the leg every shift to prevent migration and accidental dislodgement. Multiple observations over several days revealed that the catheter tubing was not secured to the resident's leg as required. Certified Nursing Assistants (CNAs) performed catheter care without securing the catheter tubing, and both CNAs confirmed that the tubing was not secured. After providing care, they still did not secure the catheter tubing to the resident's leg. Additionally, the Director of Nursing (DON) stated that nurses are educated to follow care plan interventions, but the observations and staff interviews indicated that the care plan was not being followed in practice. The failure to secure the catheter tubing as outlined in the care plan and facility policy constituted a deficiency in providing appropriate catheter care and in preventing potential catheter-related complications.