Failure to Prevent Accidents and Ensure Safe Catheter and Transfer Practices
Penalty
Summary
The facility failed to ensure resident safety and adequate supervision in three separate incidents involving residents with urinary catheters and fall risks. In the first case, a cognitively intact resident with a urinary catheter was injured when a CNA attempted to dress her by pulling the catheter system through her pants, causing a plastic clip attached to the catheter bag to lacerate her leg. The resident required emergency care and nine sutures to close the wound. The CNA later acknowledged that the catheter bag and tubing should have been managed differently to prevent contact with the resident's skin. In the second incident, a resident with a history of falls and confusion, also with a urinary catheter, was observed during therapy with her catheter drainage bag hanging from her wheelchair while she ambulated with a walker. As the resident walked, the catheter tubing was pulled taut, creating tension and pulling on her leg, as the drainage bag remained attached to the wheelchair behind her. The DON confirmed that the standard of care would be to use a leg bag or to hang the catheter bag from the walker to avoid tension on the tubing during ambulation. The third incident involved a resident with repeated falls, hearing and vision loss, and impaired mobility. During a shower, an agency CNA, who had been told the resident was independent, left her in a wheelchair while retrieving a shower chair. The resident attempted to stand on her own, lost her balance, and was lowered to the floor by the CNA. The CNA was unsure if the resident could hear or see her instructions. The DON stated that staff should verify a resident's transfer status and assistance needs using the care plan or information posted in the resident's room.