Failure to Follow Catheter Care Standards and Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to provide catheter care in accordance with standards of practice and the resident’s care plan for a resident with an indwelling urinary catheter. The resident had Alzheimer’s disease, CKD stage 3, BPH, obstructive uropathy, neurogenic bladder, weakness, and minimally impaired cognition, and required staff assistance with ADLs due to physical limitations and decreased safety awareness. The care plan directed use of a 16Fr urinary catheter for acute urinary retention with obstruction, use of a Stat-lock device to secure the catheter and reduce tugging, and monitoring of catheter output every shift. The urinary incontinence CAA documented the need for a catheter to address obstructive uropathy and to help prevent skin breakdown and UTI. Despite these directives, the resident was observed self-propelling in a wheelchair with a steady stream of apparent urine on the floor along the hallway, which staff immediately recognized as belonging to this resident. Further observations and interviews showed that catheter care practices were inconsistent with the care plan and standards of practice. During catheter care, the CNAs emptied the catheter bag and assessed the insertion site but the resident did not have a Stat-lock on the thigh to anchor the catheter tubing. A CNA stated they were supposed to empty catheter bags at the end of their shift and that a Stat-lock was not used because the resident “just takes them off.” On another occasion, the resident was observed sitting in the dining room with a full, round catheter bag hanging under the wheelchair, and nursing staff were notified. A nurse stated that CNAs typically empty catheter bags at the end of their shift, while also acknowledging that all catheterized residents should have a Stat-lock and that multiple cases were in stock. The administrative nurse stated her expectation was that the Stat-lock be used unless not tolerated, with such intolerance documented in the care plan, and also reported that the facility had no written catheter care policy and instead followed standards of practice.
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