Failure to Monitor and Document Catheter Care and UTI Signs
Penalty
Summary
The facility failed to provide appropriate monitoring and care for a resident with a suprapubic catheter, as required by both physician orders and facility policy. The resident, who had a history of sepsis, obstructive and reflux uropathy, and anemia, was identified as being at risk for urinary tract infection (UTI) due to the use of a suprapubic catheter. The care plan and physician orders specified that staff should monitor and document urine characteristics such as color, consistency, odor, and presence of blood, as well as secure the catheter with an anchor to prevent dislodgement. However, documentation in the Treatment Administration Record (TAR) indicated signs and symptoms of UTI on multiple dates, but did not specify what symptoms were observed or what interventions were provided. Additionally, there was no evidence in the nursing progress notes or catheter assessment that these symptoms were followed up with appropriate care or physician notification. Direct observations and staff interviews revealed further lapses in care. On one occasion, the resident's suprapubic catheter was observed to have pinkish urine output and a foul smell, and the catheter was not secured with an anchor, resulting in leakage. The resident reported being unable to monitor her own urine output and was not informed by nursing staff about her condition. Staff members, including a CNA and treatment nurse, confirmed that the catheter was not properly secured and that the odor was noticeable, but the treatment nurse was unaware of the pink urine until later in the day. The Director of Nursing acknowledged that the catheter should have been anchored at all times and that staff should have reported abnormal findings immediately. Interviews with nursing staff indicated a lack of detailed documentation and follow-up regarding the signs and symptoms of UTI noted in the TAR. Staff admitted that documentation was incomplete and that interventions were not clearly recorded. Facility policy required that catheter care include securing the catheter, observing for complications, and recording detailed information about urine characteristics and any unusual findings. These requirements were not met, resulting in a failure to accurately monitor and respond to potential UTIs and catheter-related complications for the resident.