Failure to Ensure Staff Competency in Securing Foley Catheter
Penalty
Summary
Nursing staff failed to demonstrate competency in securing a Foley catheter (FC) for a resident with obstructive and reflux uropathy, resulting in prolonged pain and discomfort. The resident, who was admitted with significant urinary tract issues and required an indwelling catheter, repeatedly reported pain at the catheter insertion site to both CNAs and LVNs over several days. Family members observed that the catheter was pulling and likely causing the pain, and staff confirmed the resident had been complaining of pain whenever the FC was touched or moved. Upon observation, redness and white spots were noted at the insertion site, and the FC was found unsecured. When attempts were made to secure the FC using a device, the assigned RN was unable to do so, admitting a lack of knowledge on how to use the securing device. The Director of Nursing later clarified that the facility did not use the specific securing device present and that staff should have replaced it with the device they were trained to use. The failure to secure the FC appropriately led to ongoing pain and irritation for the resident, as documented in interviews, observations, and record reviews.