Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling catheter. The resident, who had diagnoses including obstructive uropathy, congestive heart failure, and muscle weakness, had specific physician orders for catheter care. These orders included documenting foley output every shift, performing catheter care every shift, and changing the foley flush kit every night shift. However, the facility did not consistently document the completion of these orders. From April 2024 through December 2024, there were multiple instances where foley output was not documented, catheter care was not completed, and the foley flush kit was not changed as ordered. As a result of these lapses in care, the resident received antibiotic treatment for urinary tract infections on two occasions, from July 15-22, 2024, and November 3-15, 2024. The Director of Nursing confirmed that the facility's process and physician orders were not followed as expected. This deficiency was identified during a review of the facility's policy, the resident's clinical record, and through staff interviews, highlighting a failure to adhere to the care plan designed to prevent infections related to the indwelling catheter.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R37. 2) The Facility reviewed R37, for missing documentation. 3) All current residents with Catheters were reviewed for incomplete documentation, Foley care, output, and Foley Flush Kit changes. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accuracy, Foley care, documentation of output and Foley Flush Kit changes. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on 5 random residents 3x a week for 4 weeks for compliance with Foley care, documentation, output and direct observation of residents that have orders for Foley Flush Kits were done, then five (5) random residents 1x week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.