Failure to Secure Indwelling Catheter as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of chronic kidney disease, acute kidney failure, and neuromuscular dysfunction of the bladder was found without a securement device for her indwelling Foley catheter. The resident required substantial to maximal assistance with self-care and was incontinent of both bowel and bladder. Physician orders specified that the Foley catheter anchor should be changed every night shift, and the resident's care plan included interventions to prevent catheter-related trauma, such as securing the catheter and monitoring for signs and symptoms of urinary tract infection (UTI). During observations, it was noted that the resident did not have a strap or device securing the catheter tube to her thigh. The resident reported never having a securement device. Interviews with staff, including a CMA, LVN, DON, and the Administrator, confirmed that the catheter should have been secured with a leg strap according to facility policy and physician orders. The facility's policy on catheter care also specified the use of a leg band to secure the catheter. The failure to ensure the catheter was properly secured constituted the deficiency.