Deficient Incontinence and Catheter Care Practices
Penalty
Summary
Two residents were found to have not received appropriate care related to incontinence and catheter management. One male resident with severe cognitive impairment, neuromuscular dysfunction, and an indwelling Foley catheter was observed sitting on the toilet without his catheter tubing secured to his leg. During the process of cleaning and transferring the resident from the toilet to his wheelchair and then to his bed, the catheter remained unsecured. The resident complained of pain in the penile area during this process. Staff interviews confirmed that the catheter should have been secured to prevent pulling and potential injury, and that this step was missed during the observed care. Another female resident with moderate cognitive impairment, a history of septicemia, and requiring substantial assistance for toileting was observed receiving incontinence care. During the cleaning process, the CNA failed to separate the resident's labia and did not clean the area using wipes as required, instead using the brief to wipe. The resident had a bowel movement that had spread between her legs, but the cleaning did not include proper perineal care to ensure all feces was removed from the vaginal area. The CNA acknowledged the correct procedure was not followed and recognized the risk of infection if feces remained. Facility policy required that catheters be anchored with a leg strap to prevent tension and possible injury, and that proper perineal care be performed to reduce infection risk. Both deficiencies were observed directly by surveyors and confirmed through staff interviews and record review.