Failure in Catheter Management and Resident Monitoring
Penalty
Summary
The facility failed to provide necessary and appropriate care and services to prevent complications from urinary catheters for several residents. Resident #1, who had a diagnosis of prostatic hyperplasia, experienced significant issues due to improper catheter management. The nursing staff did not document the free flow of urine to verify the proper positioning of the catheter, and there was a delay in notifying the practitioner about the lack of urine output. This resulted in Resident #1 becoming unresponsive and requiring emergency transfer to an acute care hospital. The report highlights that the facility did not have processes in place to ensure ongoing assessment of residents to prevent complications from urinary catheters. This lack of proper monitoring and documentation was evident in the discrepancies between the Treatment Administration Record (TAR) and the Certified Nursing Assistants' (CNAs) documentation of urine output. The facility's failure to monitor and document urine output as ordered by the physician was also noted for other residents, such as Residents #4, #61, and #8, who had similar issues with catheter management. Additionally, Resident #999, who was incontinent, reported that staff did not respond to her requests for toileting assistance, and her daughter filed a grievance after finding her mother in soiled conditions. The facility's failure to address these issues and ensure proper care and monitoring of residents with catheters and incontinence led to the determination of Immediate Jeopardy, indicating a likelihood of serious harm or injury to the residents.
Plan Of Correction
1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: • Resident #1 no longer resides in the facility. • Residents #4, #5, #8, & #61 had an RN assessment completed. • Resident #999 was provided with care at the time of grievance. 2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: • Current residents had an evaluation completed. • Current residents had an RN assessment completed including a set of vital signs and observation for output and patency. Any changes identified were communicated to the provider and family notification completed. • Facility residents with a score of 13 or greater were interviewed regarding the facility's provision of goods and services. • Facility residents with a score of 12 or less had skin evaluations completed. 3) What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur: Education: • The facility's Staff Development Coordinator/Designee completed competencies with CNAs on emptying and measuring output for residents with. This competency was conducted using a mannequin with an to simulate the actual emptying of the. • The facility's Staff Development Coordinator/Designee completed education with CNAs to ensure that any notable changes in output for residents with and any residents experiencing a change in condition are reported immediately to the nurse. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the necessary completion of a change in condition evaluation when the following occur: o Accidents resulting in injury, or the potential to require physician intervention. o A significant change in the resident's physical, mental, or condition such as a deterioration in health, mental, visual observation of the color and clarity of output each shift. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the nurses' requirement to notify the provider of any notable changes in resident condition. • The facility's Staff Development Coordinator/Designee completed competencies with licensed nurses on the proper insertion of with return demonstrations. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on the requirement of detailed communication during shift to shift report to include any changes in condition, any new physician orders, and review of any new or existing devices including. • The facility's Staff Development Coordinator/Designee completed education with licensed nurses on ensuring new orders for include placement, patency/draining, irrigation, securement device, care Qshift, and to record the output Qshift. • The facility's Staff Development Coordinator completed competencies on the proper insertion of with return demonstrations for staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education on the identification of a change in condition with staff A, B, C, & D. • The facility's Staff Development Coordinator/Designee completed education with CNAs on completing the required ADL documentation. • The facility's Staff Development Coordinator/Designee completed education with Nurse Unit Managers and RN Weekend Supervisor on monitoring the completion of ADL documentation. System Change: • Output was added to the MAR to ensure nursing documentation. • CNAs will be responsible for emptying output for residents with and will report this number to the licensed nurse, who then will be responsible for recording the output value on the MAR three times a day. • The facility added to the orientation agenda that all newly hired licensed nurses will complete competencies on the proper insertion of with return demonstration prior to providing resident care. • The facility implemented staff huddles led by Nurse Unit Managers to address ADL documentation completion. 4) How will the corrective action(s) be monitored to ensure the deficient practice will not recur: • The facility initiated the completion of audits seven days a week including weekends and off hours on all residents to ensure vital sign orders and the proper documentation of these vital signs. These audits will be monitored by DON/designee.