Failure to Secure Foley Catheters for Two Residents
Penalty
Summary
The facility failed to ensure that two residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections. For both residents, observations on multiple occasions revealed that their Foley catheters were not secured to their legs, and no securement devices were in place as required by physician orders and facility policy. Documentation indicated that staff had marked the securement device as checked and in place on the treatment administration records, despite direct observations to the contrary. One resident, a male with neuromuscular dysfunction of the bladder and dependent on staff for all activities of daily living, had a care plan that did not address securing his Foley catheter. His physician orders specified Foley catheter care every shift and allowed for the use of a leg strap to secure the tubing. However, video evidence showed that his catheter was not secured during an observation. The treatment administration record indicated daily checks, but these were not consistent with the actual condition observed. The second resident, also a male with acute kidney failure and neuromuscular dysfunction of the bladder, was similarly dependent on staff and had an indwelling catheter. His care plan did not mention the catheter, and observations on several dates showed his Foley catheter was not secured. Staff interviews confirmed that nurses were responsible for ensuring catheters were secured, but the lack of securement was overlooked. The facility's policy required catheters to be secured with a leg strap to prevent movement and reduce infection risk, but this was not followed for these residents.