Failure to Secure Suprapubic Catheter Resulting in Dislodgement and Urine Leakage
Penalty
Summary
The facility failed to ensure proper securement of a suprapubic catheter for one resident with paraplegia and multiple urinary and renal diagnoses. Observations on two consecutive days revealed that the resident's suprapubic catheter tubing was not secured to the leg with an anchor or stabilization device, as required. The resident reported discomfort and frequent disconnection of the tubing, which led to urine leakage and saturation of bed linens. The care plan for the resident included interventions related to catheter care but did not address the need to assess securement of the tubing. Interviews with staff indicated a lack of communication and follow-through regarding the provision of securement devices. Central Supply confirmed that securement devices were available and had not been requested, while the Unit Manager stated that devices were kept in a locked office and could not explain why one had not been provided to the resident. The resident continued to experience issues with catheter dislodgement and urine leakage due to the absence of a securement device.