Facility Fails to Provide Appropriate Catheter Care

Magnolia Manor in Greenville, South Carolina has been cited after failing to “provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections” for two residents.

During an observation, the first resident’s catheter bag and tubing were found on the floor. The catheter bag was uncovered and visible from the hallway. A Licensed Practical Nurse (LPN) confirmed that the resident’s “catheter tubing was on the floor and that the catheter bag was uncovered and visible from the corridor.”

Furthermore, the resident’s care plan indicated that the facility should “assess the drainage every shift. Record the amount, type, color, odor.” However, upon medical record review, it was found that the facility was not routinely monitoring the resident’s catheter bag or its contents.

During the same observation, a Registered Nurse (RN) performed catheter care. “While cleansing around the head of the penis, the nurse proceeded to cleanse and rinse the [catheter] tubing without anchoring it to preventing pulling at the insertion site.” The resident yelled out in pain, however the RN did not address his pain. When asked by the surveyor if it hurt, the resident answered “very much.”

The surveyor also noted that a leg band was not being used “to secure the catheter from pulling at the insertion site during activities of daily living.” The RN claimed the facility doesn’t require staff to secure catheters from pulling for immobile people.

Unfortunately, this was not an isolated instance in this facility. During observation of catheter care for another resident, the tubing was again not anchored to prevent pulling on the insertion site. Review of the facility policy titled “Catheter Urinary Cleaning & Maintenance” states staff should “cleanse area at catheter insertion site, taking care not to pull” though anchoring the catheter to prevent pulling was not mentioned.

Even though the facility’s policy for catheter care did state to take care not to pull at the insertion site, they failed to mention to anchor the catheter to prevent pulling in the policy. As a direct result of this, staff did not anchor catheters during care. When catheters are not anchored, pulling at the insertion site is inevitable, directly causing immense pain to residents.

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