Failure to Timely Report Urinary Changes and Perform Hand Hygiene
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident who was always incontinent of bowel and bladder and dependent on staff for toileting. Over several days, the resident exhibited decreased urinary output and abdominal distention, which were observed and reported by CNAs to an LPN. However, the LPN did not notify a physician or APRN of these changes, instead instructing staff to continue monitoring. Documentation of the resident's urinary output and abdominal distention was incomplete, and there was a delay in transcribing and acting on an order for a urinalysis. The resident's condition worsened, resulting in hospitalization for urinary retention, UTI, and acute kidney injury, with laboratory findings confirming elevated BUN and creatinine levels. Hospital records indicated significant urinary retention, hematuria, and additional complications including stercoral proctitis and bladder wall thickening. Additionally, the facility failed to ensure proper hand hygiene practices during toileting assistance for another resident. During direct observation, a CNA was seen removing gloves after providing perineal care and changing a soiled brief but did not perform hand hygiene before leaving the room and transporting the resident to a common area. The CNA later acknowledged the omission and confirmed that hand hygiene should have been performed after providing toileting care. Facility policies required prompt notification of a physician or on-call provider for significant changes in a resident's condition, as well as documentation of such changes and adherence to hand hygiene protocols after toileting care. These policies were not followed, as evidenced by the lack of timely provider notification, incomplete documentation, and failure to perform hand hygiene, contributing to the deficiencies identified during the survey.