Deficient Catheter Care and Delayed UTI Response
Penalty
Summary
Two residents experienced deficiencies in care related to urinary catheter management and timely response to urinary tract infection (UTI) symptoms and laboratory findings. For one resident with a history of neuromuscular bladder dysfunction and recurrent UTIs, the indwelling catheter bag was not labeled with the date and time of the last change, as observed by a licensed vocational nurse. The nurse confirmed that labeling is necessary to track changes and prevent complications such as obstruction or infection. Review of the resident's treatment records and facility policy revealed no documentation of when the catheter bag was last changed, and the policy did not specify routine intervals for changing bags. Another resident, dependent on staff for personal care and with a history of renal dialysis, UTI, and diabetes, reported symptoms of dysuria and voiding hesitancy. A physician ordered a urinalysis and culture, but the urine sample was not collected promptly, and the results indicating infection were not immediately communicated to the physician. There was no documentation of a change in condition evaluation or physician notification when the urinalysis returned positive for bacteria. The resident's antibiotic treatment was delayed by nine days due to confusion over the administration route and lack of timely clarification with the physician, despite the presence of symptoms and abnormal laboratory findings. Interviews with nursing staff, the medical director, and the director of nursing confirmed that facility procedures require prompt collection of urine samples, immediate notification of abnormal lab results, and timely initiation of physician-ordered treatments. However, these procedures were not followed, resulting in delayed care and increased risk of complications for the residents involved. Facility policies reviewed also emphasized the need for immediate documentation and communication regarding changes in resident condition and abnormal laboratory values.