Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
Two residents with indwelling urinary catheters did not receive appropriate care as required by facility policy and standards. One resident, who had chronic obstructive pulmonary disease, generalized muscle weakness, and neuromuscular bladder dysfunction, was found with an unsecured urinary catheter. The resident reported discomfort and the sensation of the tubing pulling or poking, and both a treatment nurse and the Director of Nursing confirmed that the catheter should have been secured to prevent accidental pulling, dislodgement, and unnecessary pressure. Another resident, with diagnoses including urinary retention, gastrostomy status, severe sepsis with septic shock, and paranoid schizophrenia, did not receive documented daily urinary catheter care. The resident was entirely dependent on staff for activities of daily living and had a physician's order for a urinary catheter. Review of the treatment administration record and physician's orders revealed no documentation of daily catheter care since the catheter was placed. The treatment nurse confirmed that daily catheter care was the facility's standard practice to prevent infection and that documentation was necessary to verify care was provided. Facility policy required that catheters be anchored with a leg strap to prevent tension and potential injury, and that daily catheter care be documented in the medical record. Both residents did not receive care in accordance with these policies, as one had an unsecured catheter and the other lacked documentation and evidence of daily catheter care.