Failure to Provide Adequate Catheter Care and Assessment
Penalty
Summary
The facility failed to provide adequate urinary catheter care and assessment for the need of an indwelling catheter for a resident with severe cognitive impairment and a diagnosis of urinary retention. Documentation showed that licensed nurses verified the presence of a catheter fixation device for several days, but direct observation revealed that no leg fixation device was in place during incontinence care. Certified Nursing Assistants confirmed that a fixation device should be used to prevent accidental tugging, especially since the resident was known to attempt to pull out the catheter if it was uncomfortable. The Director of Nursing also acknowledged that leg straps or fixation devices are required to prevent the catheter from being pulled out. Additionally, there was no evidence that the facility had assessed the ongoing need for the indwelling catheter or attempted a voiding trial, as required by facility policy. The Director of Nursing stated that the resident had arrived with a catheter and that no voiding trial had been discussed or attempted within the first month of admission. Facility policy mandates periodic assessment and documentation to justify continued catheter use, as well as involvement of the resident or representative in discussions about catheter removal, but these steps were not completed.