Failure to Properly Secure and Maintain Foley Catheter Strap
Penalty
Summary
A deficiency was identified when a resident with multiple medical conditions, including Alzheimer's Disease, Chronic Kidney Disease, and Diabetes Mellitus, was observed with a Foley catheter strap that was not properly secured as per physician orders and facility policy. During peri and Foley catheter care, surveyors observed that the catheter strap was old, frayed, discolored, and triple wrapped around the resident's leg, causing it to slip and not remain anchored in place. Staff present during the procedure were unable to state when the strap was last changed or how often it should be replaced, and acknowledged that the strap was not fitting properly. Further interviews with nursing staff revealed a lack of knowledge regarding the proper placement and replacement schedule for the catheter strap. Record review showed that staff had documented compliance with physician orders to monitor and keep the leg strap on, but direct observation contradicted these records, as the strap was not properly secured or changed until after surveyor intervention. The facility's policy required catheter care every shift and as needed, with monitoring and documentation, but these procedures were not followed. The Director of Nursing confirmed that the catheter strap should be routinely monitored, positioned, and changed according to protocol.