Failure to Prevent Recurrent Nephrostomy Tube Dislodgement
Penalty
Summary
The facility failed to provide necessary care and services to prevent the recurrent dislodgement of a nephrostomy tube for a resident who was completely dependent on staff for all activities of daily living. The resident, who had significant medical conditions including chronic respiratory failure, anoxic brain damage, cardiac arrest, and quadriplegia, experienced multiple episodes where the nephrostomy tube became dislodged, resulting in repeated transfers to a general acute care hospital for invasive procedures. The care plans reviewed did not include specific interventions aimed at preventing the dislodgement of the nephrostomy tube, despite the resident's high risk and history of such incidents. Staff interviews revealed that the resident was unable to move or pull out the nephrostomy tube independently, and the likely cause of dislodgement was attributed to staff actions during care activities such as turning, repositioning, and bathing. Several staff members, including CNAs, LVNs, and RNs, acknowledged witnessing the tube dislodged on multiple occasions and indicated that the tube could be easily hidden under skin folds or not properly secured during care. The facility's policy and procedure for nephrostomy care required checking the placement and integrity of the tube, but there was no evidence that unlicensed staff received competency training specific to nephrostomy tube care. Documentation and interviews indicated that the care plans were updated after each incident but continued to lack preventive interventions for tube dislodgement. The repeated failure to implement effective measures to secure the nephrostomy tube and ensure staff competency in its care led to ongoing complications for the resident, including multiple hospitalizations and exposure to further medical risks.