Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with a history of paraplegia, neuromuscular bladder dysfunction, and other significant medical conditions was admitted and care planned for a Foley catheter. The care plan included monitoring for pain or discomfort due to the catheter and checking the tubing for kinks each shift. Physician orders specified the use of a Foley catheter, and facility policy required that the catheter be secured with a leg strap to reduce friction and movement at the insertion site. During observation of catheter care, it was noted that the resident did not have a Foley catheter leg strap in place. Interviews with nursing staff confirmed that the resident was supposed to have a secure leg strap to prevent pulling or dislodgement of the catheter, but the strap was not present. The resident reported that staff never attached a secure strap to the catheter tubing. Facility policy and staff interviews confirmed the expectation that all residents with Foley catheters should have a leg strap to prevent dislodgement.