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F0690
D

Foley Catheter Tubing Not Secured as Required by Facility Policy

Covina, California Survey Completed on 05-16-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident with a Foley catheter was observed with the catheter tubing not secured to the thigh, contrary to the facility's policy and procedure. The resident, who had diagnoses including type 2 diabetes mellitus, hypertension, and chronic kidney disease, was dependent on staff for most activities of daily living and required an indwelling Foley catheter for urinary retention and skin management. The care plan specified that staff should monitor the position of the catheter tubing to ensure proper urine flow, and the order summary required licensed staff to check every shift that the catheter was in place. During observation and interviews, it was confirmed by both a registered nurse and the Director of Nursing that the catheter tubing was not secured as required, and the securement device was not taped. The facility's policy indicated that the tubing should be attached to the resident's leg to prevent pulling and injury. This failure to follow established procedures had the potential to result in catheter-related complications for the resident.

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