Inadequate Catheter Care Competency Leads to Resident Harm
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to demonstrate appropriate competency in the care of a resident with an indwelling urinary catheter. The resident, who had paraplegia and neuromuscular dysfunction of the bladder, required an indwelling catheter and was dependent on staff for transfers and partial assistance with mobility. According to documentation and interviews, the CNA pulled on the resident's catheter while attempting to empty the catheter bag, resulting in the catheter leaking urine and causing the resident pain. The resident reported that the CNA was rough and did not follow the correct procedure, which led to a hospital visit for catheter displacement. The resident also expressed a preference not to have that CNA provide care in the future. Further investigation revealed that the CNA attempted to lift the mattress to remove the catheter bag, which is not in accordance with facility procedures. The leg strap securing the catheter tubing was not properly positioned, and the CNA acknowledged that it should have been placed higher on the leg or not used at all, as the resident typically did not wear it. The facility's policy requires that catheter tubing be secured with a leg strap to prevent movement and trauma. Staff interviews confirmed that the CNA did not follow established procedures for catheter care, resulting in the incident.