Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
A deficiency was identified when a resident with an indwelling urinary catheter did not receive appropriate catheter care and securement as ordered and per facility policy. The resident, a 94-year-old male with diagnoses including heart failure, sepsis, and acute kidney failure, had physician orders and care plan interventions specifying the use of a catheter leg strap and regular catheter care. During observation, the catheter was found unsecured, and the securement device was not in place as required. Certified Nursing Assistant (CNA) O performed incontinent and catheter care for the resident but did not follow proper procedures. CNA O began care at the resident's buttocks, wiped both buttocks, and applied a clean brief without changing gloves or sanitizing hands. She then changed gloves but did not wash or sanitize her hands before starting catheter care. After performing catheter care, she did not change the dirty brief or gloves before pulling up the resident's pants. These actions were observed and confirmed by another CNA and facility nursing leadership, who noted that the care sequence and hand hygiene were not in accordance with expected standards. Interviews with staff, including the CNAs, LVN, DON, and ADM, confirmed that the resident's catheter was not secured and that proper hand hygiene and care sequence were not followed. Staff acknowledged that the observed practices deviated from facility policy and training, which require front-to-back cleaning, proper glove changes, hand hygiene, and the use of a securement device for all residents with catheters. The facility's policies on urinary continence and catheter care emphasize the importance of these procedures to prevent infection and ensure resident safety.