Failure to Use Catheter Stabilization Device for Resident With Indwelling Catheter
Penalty
Summary
The deficiency involves the facility’s failure to use a catheter tubing stabilization device for a resident with an indwelling urinary catheter, despite care plan interventions to secure the catheter and prevent excess tension. The resident was admitted with bladder neck obstruction and had an indwelling catheter documented on the quarterly MDS, with orders for catheter changes as needed and routine flushing due to increased sediment. During an observation, the resident’s indwelling catheter was connected to a bedside drainage bag with visible yellow urine and sediment, and no catheter stabilization device was in place. The Assistant Director of Nursing (ADON), upon assessing the resident, confirmed that there was no device securing the catheter tubing and acknowledged that the resident should have had one in place to keep the catheter from being pulled. A nurse aide reported that on the morning of the same day, when she put the resident back to bed, she noticed the absence of a catheter stabilization device and informed the assigned nurse. The nurse aide stated the resident usually had such a device and that nurse aides were not permitted to change or replace it. The assigned nurse confirmed she had been told about the missing device, assessed the catheter, and delayed applying a new stabilization device while waiting to speak with the Nurse Practitioner (NP) in case a catheter change was needed. By the time she returned after speaking with the NP, the ADON was already in the process of changing the catheter. The NP stated she believed it was protocol for the resident to have a catheter stabilization device to prevent pulling of the catheter tubing and noted that pulling or tugging could cause trauma or pain. The Administrator also stated that if something was recommended to prevent the catheter tubing from being pulled, it should have been in place.
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