Failure to Secure Indwelling Urinary Catheters as Ordered
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, specifically by not ensuring the use of catheter securement devices (straps) to prevent pulling or tugging of the catheter tubing. Observations on multiple residents revealed that the catheter tubing was not secured with a strap, as required by facility policy and physician orders. For example, one resident was observed in bed with the catheter tubing lying across the leg and no securement device in place, while another resident had the catheter tubing hanging through pajama pants and attached to a drainage bag on a walker, also without a securement device. Record reviews showed that care plans and physician orders for these residents included instructions for catheter care, such as anchoring the tubing with a strap and checking skin integrity. However, these interventions were not consistently implemented. In one case, the care plan did not include specific interventions for positioning the catheter bag and tubing or ensuring a securement device was in place. Additionally, medication administration records did not always reflect that catheter care orders were followed as written. Interviews with staff confirmed that they were aware of the need for catheter securement devices and privacy covers for drainage bags, but could not explain why these were not in place for the affected residents. Staff described their training and responsibilities regarding catheter care, but acknowledged the absence of securement devices during the survey. The facility's own policy required the use of securement devices to prevent movement and reduce infection risk, but this was not adhered to for the residents reviewed.