Failure to Maintain Securement Device for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to secure an indwelling urinary catheter with a leg band securement device for a resident with neuromuscular bladder dysfunction and urinary retention. The resident was admitted with these diagnoses and had a physician’s order for an indwelling urinary catheter. A quarterly MDS documented that the resident was cognitively intact and had an indwelling catheter. During a wound care observation, surveyors noted that the resident did not have a leg band in place to secure the catheter tubing, although there was no tension on the tubing at that time. In an interview immediately afterward, the resident reported that staff sometimes forgot to place the securement device and was unable to recall how long it had been missing, though he denied discomfort or tension on the tubing. On a subsequent observation the next day, the resident was again seen in bed with the catheter tubing not secured, and there was still no tension on the tubing. The Infection Preventionist confirmed that the resident was supposed to have a leg band to prevent the catheter from becoming dislodged and stated that the nurse on the hall was responsible for ensuring the leg band was in place, with nurse aides expected to notify the nurse if it was missing. Nurse #4 stated that nurses were responsible for checking for the leg band and reported not being aware that it was absent. NA #1 acknowledged being informed by the Infection Preventionist that the leg band was missing and stated the resident usually had one, but she had not yet reached him on her care rounds to notify the nurse. NA #1 also stated the resident received his bath on night shift, and attempts to contact the night-shift NA who cared for the resident during the relevant period were unsuccessful. The DON stated that either the nurse or the nurse aide should have ensured the catheter tubing had a securement device in place.
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