Failure to Secure Indwelling Catheter Tubing During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary retention, who was dependent on staff for toileting and had an indwelling urinary catheter, was observed to have their catheter tubing unsecured during care. The resident's care plan specifically required that the catheter tubing be secured to prevent trauma and that staff observe and document for pain or discomfort related to the catheter. Despite these interventions, during catheter care, staff were observed to tug on the catheter tubing multiple times while providing care and repositioning the resident's brief, and the tubing was not anchored to the resident's thigh as required. Interviews with staff confirmed that the resident had not had a catheter anchor since returning from a recent hospital stay, and the CNA providing care acknowledged the absence of an anchor. The RN was unaware of the lack of an anchor, and the DON stated that all residents with indwelling catheters were expected to have an anchor to prevent trauma. The administrator deferred nursing issues to the DON and indicated that a physician order would be obtained if needed.