Failure to Secure Suprapubic Catheters as Ordered
Penalty
Summary
The facility failed to ensure that suprapubic catheters were properly secured for two residents who required securement devices as part of their care. For one resident with multiple sclerosis, muscle weakness, and other significant diagnoses, the care plan and physician orders specified the use of a catheter securement device to prevent accidental dislodgement, with orders to replace the device every seven days and as needed. Despite documentation indicating a securement device was in place, direct observation and staff interviews confirmed that the resident did not have a securement device at the time of inspection, and the resident was unaware of how long it had been missing. A second resident with paraplegia, diabetes, morbid obesity, and other chronic conditions also had a care plan and physician orders requiring a catheter securement device, with instructions for daily and shift monitoring. Observation revealed that this resident's suprapubic catheter was not secured, and both the resident and her husband reported never having seen a securement device in use during her stay. Staff interviews further confirmed the absence of the securement device. Facility policy required the use of a securement device or leg band for catheter care, but this was not followed for either resident.