Failure to Secure Indwelling Catheters with Statlock Devices
Penalty
Summary
The facility failed to ensure that residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections. Specifically, two residents with indwelling catheters did not have a Statlock catheter securement device in place during observations, despite physician orders and care plans indicating the need for such a device. For one resident, the care plan included an intervention to change the Foley tubing securement device weekly and as needed if loose or soiled, but observation revealed the absence of a Statlock. Similarly, another resident's care plan required monitoring for catheter migration and providing catheter care every shift, yet the Statlock was not in place during observation. Interviews with nursing staff and the DON confirmed that it was the responsibility of nurses to ensure the Statlock was in place to prevent accidental dislodgement of the Foley catheter. The CNA interviewed stated that while CNAs provide catheter care and report if the Statlock comes off, only nurses are responsible for placing the device. The facility's policy on catheter care also required securing the catheter with a securement device. These findings were based on direct observation, record review, and staff interviews.