Failure to Protect Resident from Neglect During Catheter Care and Dressing
Penalty
Summary
A deficiency occurred when staff failed to protect a resident from neglect during the provision of catheter care and dressing. The resident, who had a history of traumatic spinal cord dysfunction, anemia, neurogenic bladder, lymphedema, and frail skin, was dependent on staff for all toileting and hygiene needs. According to the care plan, a string was to be used to hang the Foley catheter bag, not a plastic clip. However, staff placed the catheter bag down the leg of the resident's pants while dressing her, contrary to the care plan instructions. During the dressing process, the hook from the urine bag caught the resident's leg, resulting in a laceration on the right anterior medial shin. The wound was described as a v-shaped skin flap with visible fatty tissue and serosanguinous discharge, and the surrounding skin was noted to be shiny, fragile, and edematous. The injury required assessment by a physician assistant and transfer to the emergency room, where it was determined that the wound was non-reparable and was closed with steri-strips. Staff interviews and documentation confirmed that the injury occurred as a direct result of improper handling of the catheter bag during dressing. The resident reported that staff continued to use the same technique despite her daughter's request for a different approach. The facility's own investigation acknowledged that the catheter bag should not have been threaded through the resident's pants, and staff were subsequently educated on safer practices.