Failure to Provide Proper Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide proper care and services for two residents with indwelling urinary catheters, resulting in multiple deficiencies. For one resident with a history of acute kidney failure, benign prostatic hyperplasia, and obstructive and reflux uropathy, the facility did not monitor urine output for hematuria as required by the care plan and physician documentation. Observations revealed that the resident's catheter tubing was not anchored to the leg, and the urine in the drainage bag was dark yellow to dark red, cloudy, and contained visible sediments and blood. Staff interviews confirmed that the catheter was not secured, and abnormal urine characteristics were not reported to the physician. Additionally, there was no documentation of catheter care or monitoring after the resident returned from the hospital, and catheter care orders were not in place until after the deficiency was observed. Another resident with similar diagnoses and a suprapubic catheter also did not receive appropriate monitoring or care. The care plan required daily treatment of the catheter site and monitoring of urine for sediment, cloudiness, odor, blood, and output. However, observations showed that the resident's catheter was not anchored, there was no wound dressing at the stoma site, and the urine was yellow, cloudy, and contained sediments. Staff acknowledged that these findings indicated a potential infection and should have been reported to the physician, but there was no evidence that this was done. The facility's policy required securement of catheters and prompt reporting of unusual urine findings, but these procedures were not followed. Record reviews and staff interviews further confirmed that both residents' catheters were not properly anchored, and abnormal urine findings were not documented or reported as required. The Director of Nursing acknowledged the failures in monitoring, documentation, and adherence to physician orders and facility policy. These deficiencies resulted in the presence of abnormal urine characteristics and laboratory findings indicating infection or inflammation, without appropriate assessment or intervention by the facility staff.