Failure to Maintain Proper Catheter Care
Penalty
Summary
The facility failed to provide appropriate care for residents with urinary catheters, leading to a potential risk of urinary tract infections (UTIs) for two residents. Resident 83, who was admitted with diagnoses including Parkinson's disease and neurogenic bladder, was observed with a urinary catheter tubing that had a loop, which was confirmed by an LVN. The loop in the tubing contained urine, which could prevent urine from flowing freely and potentially cause a UTI. The Director of Nursing (DON) confirmed that catheter tubing should be positioned properly to prevent loops or kinks, as these can lead to urine backing up into the bladder. Similarly, Resident 53, who had severe cognitive impairment and required total assistance with activities of daily living, was also observed with a loop in the urinary catheter tubing. This was confirmed by another LVN, who stated that the loop could cause urine to back up into the bladder, increasing the risk of a UTI. The DON reiterated the importance of ensuring that catheter tubing is free from loops or kinks to maintain unobstructed urine flow. The facility's policy and procedure on indwelling catheter use, as well as clinical guidelines for preventing catheter-associated UTIs, emphasize the need to maintain unobstructed urine flow and keep catheter tubing free from kinks. However, the observations and interviews indicate that these guidelines were not followed, resulting in a deficiency in the care provided to residents with urinary catheters.
Plan Of Correction
B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: Residents using indwelling catheters that have kinks or loops in their tubing are potentially affected. The Director of Nursing audited all residents who have an indwelling catheter on 2/26/2025 to identify residents whose drainage tubes are kinked or looped, in order to identify other residents who may be affected by the facility practice. No other residents' catheter drainage tubing was kinked or looped. No other residents were identified as affected by the facility practice. C. What measures will be put into place or what systematic changes the facility will make to ensure that the deficient practice does not recur: The Director of Nursing/designee will re-educate the licensed nurses on or before March 21, 2025, regarding the facility policy and procedures "Indwelling Urinary Catheters," with emphasis on ensuring proper placement of the urinary drainage tubing to prevent kinks or loops, thereby decreasing the potential for urine backflow and the development of urinary tract infections. The Interdisciplinary Team (IDT) will review physician orders received since the prior business day each day during the daily clinical meeting held five times weekly. This review aims to identify residents admitted with urinary drainage catheters to ensure interventions are in place to prevent tubing from being kinked or looped, reducing the potential for urinary tract infections, and to ensure these interventions are documented on the care plan. The IDT will review the care plans of all residents with indwelling urinary catheters to ensure they receive the necessary care and services to reduce the potential for recurrent urinary tract infections, including proper placement of the urinary drainage tubing, on or before 3/13/2025. No other residents' catheter drainage tubing was kinked or looped. No other residents were identified as affected by the facility practice. The Director of Nursing/designee will re-educate the licensed nurses on or before March 21, 2025, regarding the facility policy and procedures "Indwelling Urinary Catheters," with emphasis on ensuring proper placement of the urinary drainage tubing to prevent kinks or loops, thereby decreasing the potential for urine backflow and the development of urinary tract infections. The IDT will review physician orders received since the prior business day each day during the daily clinical meeting held five times weekly. This review aims to identify residents admitted with urinary drainage catheters to ensure interventions are in place to prevent tubing from being kinked or looped, reducing the potential for urinary tract infections, and to ensure these interventions are documented on the care plan. The IDT will review the care plans of all residents with indwelling urinary catheters to ensure they receive the necessary care and services to reduce the potential for recurrent urinary tract infections, including proper placement of the urinary drainage tubing, on or before 3/13/2025. The Director of Staff Development/designee will continue to provide indwelling urinary catheter care training to nursing employees upon hire, annually, and as needed as part of the facility’s training and education program. The Director of Staff Development orients newly hired staff on the facility policy and procedure for indwelling urinary catheters. The DSD will provide skill competency verification to the certified nursing assistants (CNAs) at the time of hire for the placement of urinary catheter drainage tubing to ensure CNAs have the necessary skills to reduce the potential for UTIs by ensuring the urinary drainage tubing is not kinked or looped. Employees identified with variance to the standard of practice; and this plan of correction, will be re-educated with skill evaluation at the time of identification. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Infection Prevention Nurse will monitor residents with indwelling catheters at the time of admission or when a new catheter is placed to ensure person-centered interventions to reduce the risk for recurrent urinary tract infections are present on the care plan and that the nursing staff places the urinary drainage tubing properly to ensure kinks or loops are not present in the tubing. The charge nurse will monitor residents with indwelling urinary catheters to ensure drainage is properly placed, to reduce the risk of urinary tract infections to the extent possible. The Infection Prevention Nurse/designee will report trends identified in kinked or looped urinary drainage tubing to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025