Failure to Secure Indwelling Urinary Catheter as Required by Policy
Penalty
Summary
The facility failed to secure an indwelling urinary catheter for one resident who had a diagnosis of urinary retention and required substantial to maximal assistance with toileting hygiene. Facility policy required staff to secure the catheter using a leg band and to replace the securement device every seven days or as needed, alternating sites. The resident's care plan also directed staff to secure the catheter tubing to prevent accidental dislodgement. However, during observations, the resident was found without a securement device in place, and only a piece of tape was noted wrapped and knotted on the catheter tubing, not attached to the resident's leg. Interviews with staff revealed uncertainty about when the securement device was last used for the resident, and some staff were unaware of the current status of the catheter's securement. The LPN confirmed that policy required monitoring every shift to ensure the device was in place, but no reports had been made about its absence. The DON and Administrator both stated that the catheter should be secured to prevent displacement and trauma, and that staff were expected to report and address any issues with securement devices.