Failure to Assess and Address Catheter Complications and Missed Urology Follow-Ups
Penalty
Summary
Two residents with indwelling urinary catheters experienced deficiencies in care related to the identification, assessment, and management of catheter complications. For one resident with a suprapubic catheter, excessive sediment was observed in the tubing, and the resident reported pain. Despite repeated reports from CNAs about the catheter's condition and the resident's discomfort, there was no documented assessment, care plan, or follow-up by licensed nursing staff. The resident also missed a scheduled urology follow-up appointment, and there was no documentation of weekly catheter care or physician notification regarding the catheter's condition. Another resident with an indwelling Foley catheter was observed to have increasing amounts of white sediment in the catheter tubing over several days. The resident had a history of urinary retention and a recent surgical procedure, with a physician order for a urology follow-up within two weeks of admission. However, the follow-up appointment was not scheduled in a timely manner, and staff failed to report the changes in the catheter tubing to the physician as required by the care plan. Both the Infection Preventionist and the DON confirmed that staff should have recognized and reported the changes in the catheter tubing and that the follow-up appointment should have been arranged promptly. Facility policy required daily assessment and documentation of catheter care, including monitoring for unusual appearance, sediment, and signs of infection, as well as prompt reporting of changes to supervisors and physicians. In both cases, there was a lack of timely assessment, documentation, and physician notification regarding catheter complications, and scheduled urology follow-up appointments were missed or delayed.