Failure to Provide Proper Catheter and Nephrostomy Tube Care
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters and nephrostomy tubes, as evidenced by observations and documentation reviews. Resident 1, who was cognitively impaired and required assistance with care needs, had an indwelling urinary catheter. Observations revealed that the catheter drainage bag and tubing were in direct contact with the floor, contrary to facility policy. Additionally, there was no documented evidence of monitoring and documenting the resident's urinary output on several specified dates and shifts, as required by the care plan and facility policy. Resident 37, who was cognitively intact and required assistance with care needs, had a nephrostomy tube due to diagnoses including diabetes and obstructive uropathy. The facility's policy required monitoring and documenting the nephrostomy tube output, but there was no documented evidence of this being done on multiple specified dates and shifts. Interviews with the Director of Nursing confirmed the lack of documentation for both residents, indicating a failure to adhere to the care plans and facility policies. The deficiencies highlight the facility's failure to ensure that residents with urinary catheters and nephrostomy tubes received appropriate care and monitoring. The lack of adherence to established protocols for catheter and nephrostomy tube care, as well as the failure to document output, contributed to the deficiency findings. These actions and inactions were confirmed through staff interviews and a review of clinical records.
Plan Of Correction
Resident 1: Indwelling urinary drainage bag and tubing were removed from the floor and catheter bag changed immediately. Unable to retroactively document catheter output. Resident 37: Unable to retroactively document Nephrostomy tube output. An observation audit was completed to identify other residents with urinary catheters to validate catheter drainage bag and tubing were not in contact with the floor. Documentation audit completed related to obtaining catheter output. Nursing staff were educated by the Infection Control Nurse on keeping indwelling urinary catheter bag and tubing off the floor, Chain of Infection, and documentation. Monitoring will be captured through visual observation for placement of catheter bag and tubing. Complete 2 resident observations weekly for 4 weeks, then 4 resident observations 2 times monthly for 2 months. Monitoring will be captured through auditing charting of output on indwelling foley catheters. Audits will be conducted on 2 resident records weekly for 4 weeks, then 4 resident records 2 times monthly for 2 months. The audits will be conducted by the Infection Control Nurse or designee. Results of the audits will be provided to the Administrator by (DON) and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting monthly for a period of three months. Any revisions to the audit plan will be reviewed and implemented with the coordination of the Interdisciplinary team at QAPI Committee meeting.