Failure to Maintain Catheter Tubing Free from Sediment
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter was observed to have accumulated whitish urine sediments in the catheter tubing on multiple occasions. The resident had a history of urine retention and an enlarged prostate, with physician orders specifying regular monitoring of the catheter, cleansing, and irrigation as needed for clogging. Despite these orders, observations revealed that the catheter tubing was not free from sediment, and this was confirmed by a licensed nurse who acknowledged the presence of accumulated sediments and stated that it should not be present. Interviews with facility staff, including the DON and the administrator, confirmed that the expectation was for nurses to monitor for and address any accumulation of urine sediments in catheter tubing to prevent complications. The facility's policy also indicated that catheters should be changed before blockage is likely to occur, especially for residents prone to encrustations. The failure to maintain the catheter tubing free from sediment represented a lapse in following both physician orders and facility policy for catheter care.