Failure to Secure Foley Catheter as Ordered
Penalty
Summary
A deficiency was identified when a male resident with a history of prostate cancer and benign prostatic hyperplasia, who had an indwelling Foley catheter, was found to have his catheter unsecured to his leg. The resident reported that the catheter had been unsecured for several days and that he had informed staff, but the issue was not addressed. The resident's care plan and physician orders required the catheter to be secured to prevent trauma and infection, and the facility's policy instructed staff to minimize friction or movement at the insertion site, although it did not specifically address securement. Interviews with nursing staff and facility leadership confirmed that the responsibility for ensuring the catheter was secured rested with the nurses and other care providers. Despite this, the catheter remained unsecured, and staff were unable to provide a reason for the lapse. The deficiency was observed during a survey, and documentation supported that the required interventions to secure the catheter were not followed as ordered.