Failure to Provide Timely and Appropriate Urinary Catheter Care
Penalty
Summary
The facility failed to provide appropriate urinary catheter care and timely assessment for three residents with indwelling catheters, resulting in actual harm to one resident. One resident with multiple comorbidities, including chronic kidney disease and neuromuscular bladder dysfunction, experienced no urinary output for two days and minimal output on the third day. Despite documentation of blood in the Foley catheter and the resident's increasing pain, staff did not properly irrigate or change the catheter, nor did they notify the physician in a timely manner. The resident's wife repeatedly requested intervention, and the resident was eventually transferred to the hospital, where a blocked catheter was found, requiring replacement, continuous bladder irrigation, and pain management. Another resident with a history of neuromuscular bladder dysfunction and chronic kidney disease had a Foley catheter with milky, foul-smelling urine that was not promptly reported to the physician. The catheter bag was tinted, making urine assessment difficult, and the last documented assessment was nearly a month prior. The physician was not notified until after the urine was observed to be abnormal, and a urinalysis and culture were delayed. The resident was later found to have a urinary tract infection with specific bacteria identified, and antibiotic treatment was started only after the delay. A third resident with a suprapubic catheter and neuromuscular bladder dysfunction did not have current orders for regular catheter changes, irrigation, or equipment changes following a recent hospitalization. The resident's care plan and urology recommendations for monthly catheter changes were not reflected in current orders, and staff were unable to change the catheter as required, resulting in the resident being sent to the hospital. Facility policy required monitoring and reporting of catheter-related issues, but these were not consistently followed for the residents involved.