Failure to Secure Indwelling Urinary Catheter per Physician Order and Policy
Penalty
Summary
A deficiency was identified when staff failed to secure a resident's indwelling urinary catheter as ordered by the physician and as required by facility policy. The resident, who had diagnoses including neuromuscular bladder dysfunction, heart failure, and dementia with severe cognitive impairment, was admitted with an order for the catheter to be anchored with a stabilization device to reduce pulling and friction. The care plan also specified the use of a Foley catheter strap to prevent catheter-related trauma. During observation, the resident was found with an unsecured catheter, and a nurse confirmed that the catheter was not anchored to the resident's leg or bed, despite the existing physician order and care plan instructions. Further review of facility policy indicated that staff were required to secure urinary catheters with a leg strap to minimize movement and friction at the insertion site, and to report unsecured catheters to a supervisor. The deficiency was confirmed through observation, staff interview, and record review, which all indicated that the required stabilization device was not in place, and the catheter was not properly secured as per physician orders and facility policy.