Failure to Secure Indwelling Catheter as Ordered
Penalty
Summary
A deficiency was identified when a resident with an indwelling foley catheter was observed to have the catheter unsecured to her leg, contrary to physician orders and the facility's care plan. The resident, an elderly female with diagnoses including diabetes, dementia, protein calorie malnutrition, and urine retention, had a care plan and physician order requiring the catheter to be secured with a stabilizer and checked every shift. Despite documentation indicating compliance, direct observation revealed the catheter was not secured, and both a CNA and an LVN confirmed the absence of a securement device during their checks. The LVN noted that the resident often removed the adhesive part of the securement device, but acknowledged the catheter should be properly secured to prevent trauma or bleeding. Interviews with facility staff, including the DON and Administrator, confirmed the expectation that catheters be properly secured and that it was the responsibility of the nursing team to ensure this. The facility's policy on urinary catheter care also required the use of a securement device to prevent complications. The failure to secure the catheter as required was directly observed and acknowledged by staff, representing a lapse in following established care protocols for catheter management.