Failure to Maintain Proper Indwelling Catheter Positioning and Securement
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate indwelling urinary catheter care for one resident, specifically by allowing the catheter tubing and drainage bag to rest on the floor and by not ensuring use of a catheter securement device as care-planned. On multiple observations over two days, the resident’s indwelling urinary catheter was seen hanging from the right side of the bedframe with the drainage bag resting on the floor, and no securement strap was present on either thigh. The resident had been admitted with benign prostatic hyperplasia with lower urinary tract symptoms, obstructive and reflux uropathy, unspecified hydronephrosis, and urinary retention, and the quarterly MDS documented an indwelling urinary catheter. The resident’s care plan, initiated and later revised, specified a 16F coude indwelling catheter with interventions including use of a catheter strap, weekly strap changes, and checking strap placement every shift. During interview and observation, an LPN stated she was responsible for ensuring CNAs provided catheter care but acknowledged she had not assessed the resident for a securement strap; when she observed the resident, there was no strap in place and the drainage bag was on the floor, and she did not replace the strap at that time. Later, an RN reported being informed at shift change that the resident did not have a securement strap and showed that she had replaced the strap on the left thigh; however, the catheter tubing was found positioned under the resident’s right thigh and had to be repositioned. The Infection Preventionist stated that resting an indwelling catheter drainage bag on the floor placed the resident at risk of bacterial contamination. Review of training records showed the LPN lacked an annual competency skill check-off for indwelling catheters, and the facility’s indwelling catheter care policy required ensuring straps were snug but not tight.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.