Failure to Follow Urinary Catheter Care Policy
Penalty
Summary
The facility failed to follow its Urinary Catheter Care policy for three out of four residents reviewed for indwelling catheter care. One female resident with moderate cognitive impairment was observed with her indwelling catheter bag placed flat on the bed, contrary to the care plan intervention requiring the bag and tubing to be positioned below the level of the bladder. During catheter care, a CNA used soap and water to wipe down the catheter but did not clean the labia, stating it was difficult to do so while the resident was in a geriatric chair. Another female resident with mild cognitive impairment was found with an indwelling catheter that was not secured to her thigh, lacking a stat lock or tape as required by policy. A male resident with moderate cognitive impairment was observed with a urine leg bag tied to his thigh, but the catheter itself was not secured. During catheter care for this resident, staff used soap and water to clean the catheter but did not retract the foreskin to clean the catheter-meatal junction, as required for uncircumcised males. Staff interviews confirmed that proper procedures were not followed, including securing catheters to prevent tension, maintaining gravity drainage, and performing appropriate hygiene for both male and female residents. The facility's policy specifies these requirements, but observations and staff statements indicated noncompliance in multiple instances.