Failure to Secure Indwelling Catheter Tubing with Anchoring Device
Penalty
Summary
A deficiency was identified when a resident with benign prostatic hyperplasia and urinary obstruction, who had an indwelling urinary catheter, was not provided with an anchoring device for the catheter tubing as ordered by the physician and outlined in the care plan. The resident reported that the catheter tubing was sometimes pulled during care, and direct observation confirmed the absence of an anchoring device. Staff interviews revealed that a nurse aide noticed the missing device and informed a nurse, who had previously removed the soiled anchoring device but was unable to find a replacement. The nurse stated she reported the need for a new device to another nurse, but this was not recalled by the recipient, and the device was not replaced in a timely manner. Further interviews with nursing staff and facility management confirmed that all residents with indwelling urinary catheters should have anchoring devices in place to prevent pulling and trauma, unless otherwise care planned. The Director of Nursing acknowledged that the necessary devices should be accessible to staff and that the lack of an anchoring device was not excusable, even on a busy hall. The deficiency was based on the failure to secure the catheter tubing as required, resulting in the resident being left without the prescribed anchoring device for a period of time.