Failure to Secure Foley Catheter for Resident with Indwelling Catheter
Penalty
Summary
A deficiency was identified when a male resident with a history of benign prostatic hyperplasia and obstructive uropathy, who required a suprapubic catheter, was observed to have his Foley catheter unsecured during a survey. The resident was dependent on staff for toileting and had an order in place for staff to check the securement of his catheter every shift. During the survey, both the Assistant Directors of Nursing (ADONs) and the charge nurse were unable to explain why the catheter was not secured, and the catheter strap was not found in the resident's clothing. The facility's care plan and policy required the catheter to be anchored with a leg strap to prevent trauma and infection, but this was not followed at the time of observation. Interviews with nursing staff and the Director of Nursing (DON) confirmed that catheters were supposed to be checked and secured every shift, and that failure to do so could result in trauma or infection. The DON and Administrator both stated that monitoring catheter securement was their responsibility, but neither had noticed issues prior to the survey. The facility's policy specifically outlined the need to anchor catheters to prevent complications, yet this protocol was not adhered to for this resident.