Failure to Ensure Catheter Anchor in Place During Resident Care
Penalty
Summary
A resident with a history of diabetes, neurogenic bladder, and multiple sclerosis, who was dependent on staff for mobility and used a Foley catheter, did not have a catheter anchor in place during wound care. The resident's care plan and physician orders required the use of a catheter anchor or leg strap to secure the catheter and prevent pulling or trauma. During an observation, it was noted that the resident was lying in bed with the head of the bed slightly elevated and did not have a catheter anchor in place while being turned for wound care, creating a risk for the catheter to be pulled. Staff interviews confirmed that the catheter anchor was last seen in place earlier that morning, but was not present during the observed wound care. The wound care nurse and CNA acknowledged the importance of the catheter anchor and recognized the risk of not having it in place. The Director of Nursing was unaware of why the anchor was missing and stated that both CNAs and nurses were responsible for ensuring it was in place. Facility policy required the catheter to be secured with a leg band or tape, but this was not followed during the observed care.