Inadequate Monitoring of Tubing Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident, as evidenced by observations of the tubing being kinked and touching the floor. The resident was observed in bed with a system in progress at 2 liters per minute, and no apparent distress was noted. However, the tubing was observed to be kinked in a circle and not properly draining. A Registered Nurse (RN) was present and was notified about the kinking, after which the RN straightened the tubing to allow free flow. The RN mentioned that they round every morning to check the tubing, but did not notice the kink due to the night nurse working with the system. Further observations revealed the tubing touching the floor, which was attributed to the bed being lowered too low. A Licensed Practical Nurse (LPN) stated that they round every two hours and communicate with the Certified Nursing Assistant (CNA) about required interventions. The CNA confirmed receiving in-services on care and stated that they ensure the collection bag does not touch the floor and is anchored to the bed. Despite these measures, the tubing was found touching the ground, indicating a lapse in monitoring and intervention. The resident had a significant change in status, with a diagnosis that included neuropathic conditions. The care plan for the resident included checking tubing for kinks and ensuring proper drainage. However, there was confusion among staff regarding the type of system in place, as the LPN was unaware of a change from one system to another. The Director of Nursing (DON) acknowledged the need for staff to monitor the system to ensure proper drainage and prevent tubing from touching the floor. The physician orders were updated to reflect the correct system in use.
Plan Of Correction
Identify patients that were at risk and what did: Once identified by surveyor, the staff addressed the issue for resident #2, the tubing being kinked and tubing touching the floor. Thereafter, a full house audit was completed after surveyors identified the issues of cath care and rooms were checked for compliance. All rooms were checked for safety. All nurses and CNAs were educated on control and the difference between super pubic and regular. How will you identify other patients that are at risk: Thereafter, a full house audit was completed after surveyors identified the issues of care and rooms were checked for compliance. All rooms were checked for safety. All nurses and CNAs were educated on control and the difference between super pubic and regular. Measures put in place: A clinical inservice was held to discuss care. The supervisor that is on site will provide a new QAPI Comprehensive Supervisor Rounding tool form that spot checks rooms with safety as far as positioning and ensuring that it is not touching the floor. Additionally, the supervisor form will be handed to the DON for compliance tracking. The DON created a care random audit observations checklist. How will you monitor: The DON and/or designee will be responsible for bringing the findings and summary to the QAPI Committee. This will occur monthly for 3 months, then quarterly and/or if any variances are reported ongoing.