Inadequate Healthcare Leads to Risk of Dislodgement
Penalty
Summary
The facility failed to provide adequate and appropriate healthcare to prevent the potential risk of dislodgement for two residents. Resident #7 was observed in the hallway carrying his drainage bag in his hand and at times placing it on the floor, which increased the risk of dislodgement. Staff, including an LPN and the Director of Nursing (DON), acknowledged the risk and attempted to educate the resident about the dangers of having the bag on the floor. Despite these efforts, the resident did not consistently follow instructions, and was observed ambulating unsteadily in the hallway with the bag in his hand. Resident #8 was observed exiting the elevator with the drainage bag on his lap and the tubing on the wheelchair's wheels, which also increased the risk of dislodgement. The resident was later seen returning to his room after playing bingo, with the bag and tubing positioned close to the wheelchair's wheels. The DON was present and acknowledged the concerns, noting that the resident sometimes moved the bag around. Medical records for Resident #8 indicated a diagnosis of prostatic hyperplasia without lower tract symptoms, and care plans focused on managing the resident's condition to prevent complications. Both residents had specific physician's orders and care plans that included regular care and monitoring of their drainage bags. However, the facility's failure to ensure proper positioning and securing of the bags, as well as the residents' non-compliance with instructions, led to the increased risk of dislodgement. The observations and interviews with staff highlighted the deficiency in providing adequate healthcare to prevent potential risks associated with the residents' conditions.
Plan Of Correction
Facility denies and disputes the validity of this citation and completes this POC solely to meet the requirements of State licensure and Federal regulations. Facility further denies any and all statements, acknowledgements, confirmations, or comments attributed to facility staff as strictly hearsay. 1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice; Resident #7: The drainage bag was properly placed on the frame of the bed by the Director of Nursing. Resident #7 did not suffer any adverse effects from the drainage bag being on the floor. Resident #8: Nursing staff to provide a bag when out of bed to mitigate risk of tubing getting caught in the wheelchair wheel spokes and so the resident does not place the drainage bag on his lap. How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; Quality review by the DON/designee of current residents with an indwelling catheter to ensure drainage bags are secure and not on the floor, and that the drainage bag is covered, to be completed by [date]. 3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; Current licensed nurses are re-educated by the DON/designee on the components of this regulation to ensure drainage bags are secure, not on the floor, and that the drainage bag is covered, to be completed by [date]. 4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place; DON/designee to conduct ongoing quality monitoring through visual observation of residents with an indwelling catheter to ensure drainage bags are secure and not on the floor.