Failure to Secure and Maintain Urinary Catheters in a Sanitary Manner
Penalty
Summary
Surveyors identified that the facility failed to provide appropriate care for residents with indwelling urinary catheters, specifically by not securing catheters to prevent pulling and injury, and not maintaining catheters in a sanitary manner. Observations revealed that three residents with urinary catheters did not have their catheters properly secured to their legs as required by facility policy and physician orders. In multiple instances, catheter tubing was found to be taut, pulling, or stretched, and drainage bags were attached to bed frames without privacy covers. One resident reported discomfort and the need to hold the catheter during care to prevent pain, while another resident's catheter tubing was observed wrapped around a bedside table. Staff interviews confirmed that securement devices were not consistently applied, and that some staff believed only nurses, not CNAs, were responsible for securing catheters. Additionally, sanitary practices were not maintained, as one resident's catheter drainage bag, tubing, and valve stem were observed lying on the floor. The same resident requested a dignity bag to facilitate mobility, indicating awareness of proper catheter care. Staff acknowledged that keeping catheters off the floor was part of their training, but this was not consistently practiced. These findings were corroborated by direct observation, resident interviews, and staff statements, demonstrating a failure to follow established protocols for catheter care and infection prevention.