Failure to Secure Indwelling Urinary Catheter Tubing
Penalty
Summary
A deficiency was identified when a resident with a history of bladder rupture and urinary retention, who was admitted with an indwelling urinary catheter, was observed without a securement device on the catheter tubing. During catheter care performed by a nurse aide, it was noted that the tubing was not secured to prevent pulling, although there was no tension observed at the time. The resident confirmed that staff did not consistently apply a securement device to her catheter. Interviews with staff revealed inconsistent understanding of responsibility for ensuring the catheter securement device was in place. The nurse aide believed it was the nurse's responsibility, while the nurse stated that nurse aides should notify nurses if the device was missing or soiled. The DON indicated that either the nurse or nurse aide could apply the securement device, and the Administrator expected staff to place and check the device each shift. Despite these expectations, the securement device was not consistently used for the resident.