Failure to Ensure Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care for a resident with an indwelling urinary catheter, as evidenced by the catheter bag and tubing being observed in direct contact with the floor, without a privacy bag or barrier. This was confirmed by a nurse aide and the Nursing Home Administrator, who acknowledged that the catheter bag should have been placed in a basin, which was found under the resident's bed. The resident, who was cognitively intact and required assistance with care needs, had a diagnosis of obstructive uropathy and a physician's order for a suprapubic catheter. Additionally, the facility did not adhere to its policy of measuring and documenting urinary output for residents with indwelling catheters every shift. A review of the resident's records revealed multiple instances where urinary output was not documented across various shifts from February to April. The Nursing Home Administrator confirmed the lack of documentation for the specified dates and shifts, indicating a failure to comply with the facility's policy on intake and output measurement.
Plan Of Correction
The remedy could not be immediate as the events occurred in the past. All residents with Urinary Catheters were identified and a documentation Audit was completed. The Input and Output Measurement policy was reviewed and updated. This Policy will be educated and reviewed with All current Healthcare Nursing Staff and acknowledgements will be obtained and documented. All newly hired staff as well as temporary (agency) staff and Hospice Agencies that provide care are to be educated on the documentation of output. The Director of Nursing, Assistant Director of Nursing, Healthcare Nursing Leadership, or designee will conduct audits for staff compliance with documentation of output in indwelling catheters three times weekly for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting. (Catheter Bag touching the Floor) Upon immediate investigation it was determined that all necessary supplies were in place to ensure that residents Urinary Catheter and any accompanying tubing were not in direct contact with the floor, however due to the residents bed being placed in the appropriate care Planned position, the bed frame had inadvertently crushed the basin allowing for the tubing and bag to be in contact with the floor. As this facility considers this a random unusual occurrence, the following will be completed in efforts to ensure that staff continue to remain educated and diligent in ensuring the mentioned deficiency does not occur. Policy was reviewed for accuracy and appropriateness. The Director of Nursing, Assistant Director of Nursing (Infection Preventionist), Healthcare Nursing Leadership, or designee will conduct visual audits for staff compliance with ensuring urinary Catheter Bags and Tubing are meeting Infection Control Standards three times weekly for two weeks, then weekly for six weeks, then monthly for four months. On-the-spot education will be provided to staff as needed. The results of these logs/audits along with a Root Cause Analysis of any identified issues will be brought to the Quality Assurance and Performance Improvement Committee for two quarters for further analysis and corrective action as needed. The committee will determine the need for additional audits or reporting.