Failure to Provide Proper Catheter Care and Securement
Penalty
Summary
The facility failed to provide proper catheter care for four residents, as evidenced by observations, interviews, and record reviews. Catheter drainage bags were not changed according to physician orders, with some bags dated well beyond recommended intervals. Multiple residents were observed with catheters lacking adhesive or stabilization devices, despite facility policy requiring securement to prevent movement and urethral traction. Cloudy catheter lines and sediment were noted, and staff responses to these findings were inconsistent, with some staff indicating irrigation or culture requests, but not adhering to established protocols. One resident had a pressure injury corresponding to the location of an unsecured catheter, and the Director of Nursing confirmed that securement devices were not in use, contrary to both facility policy and best practice guidelines. Staff interviews revealed that while in-service training on catheter care had occurred recently, there was no consistent application of securement practices, and demonstration training had not yet started. The facility's own policy and external best practice guidelines both emphasize the importance of securing catheters to prevent complications, but this was not implemented. Residents with a history of frequent UTIs and catheter-related wounds were not receiving care in accordance with these standards, as evidenced by the lack of securement and timely bag changes.