Failure to Ensure Catheter Securement Device in Place During Care
Penalty
Summary
A deficiency was identified when a resident with dementia and neuromuscular dysfunction of the bladder did not have a urinary catheter securement device in place during a catheter care procedure, despite an active physician order and care plan requiring its use to prevent movement and urethral traction. The care plan specified that the securement device should be monitored every shift, and documentation indicated compliance earlier in the day. However, during direct observation by surveyors, the securement device was not present, and staff interviews confirmed its absence at that time. Further review of the resident's records, including progress notes and the care plan, revealed no documented behaviors indicating that the resident removed the securement device. Staff members, including a CNA, DON, and LPN, acknowledged having seen the device in place previously but did not verify its presence during the shift in question. The facility's catheter care policy required the use of a leg strap to secure the catheter, which was not followed during the observed care, resulting in noncompliance with established protocols.