Failure to Secure Foley Catheter as Ordered
Penalty
Summary
A deficiency occurred when a male resident with neuromuscular dysfunction of the bladder, who was severely cognitively impaired and required assistance with all activities of daily living, was observed without his Foley catheter being secured to his leg as required. The resident's care plan and physician orders specified that the catheter should be secured with a leg strap and monitored twice daily to prevent catheter-related trauma. On the date of observation, no securement device was present, and the Foley catheter was not attached to the resident's leg. Interviews with nursing staff, including an LVN, the ADON, and the DON, confirmed that it was the responsibility of the nursing staff to ensure the catheter was properly secured according to facility policy and physician orders. The LVN admitted to not checking the securement device at the start of her shift and was unaware that it was missing. Facility policy, revised in August 2022, also required that urinary catheters remain secured to prevent complications. The failure to secure the catheter as ordered and per policy constituted the deficiency.