Failure to Implement Bladder Training and Maintain Catheter Care Standards
Penalty
Summary
The facility failed to develop and implement interventions to attempt to restore or improve bladder function for a resident with urinary incontinence. The resident, who had diagnoses including heart failure and diabetes and was assessed as always incontinent of urine and frequently incontinent of bowel, was found to have intact cognition and the ability to communicate the urge to void. Despite an assessment indicating the incontinence was likely reversible and that the resident could participate in a toileting program, there was no evidence in the clinical record of a bladder training program or other interventions being carried out to address the incontinence. The resident also reported not recalling any bladder training or interventions to assist with regaining continence. Additionally, the facility failed to ensure proper catheter care for another resident with a suprapubic catheter. Observations showed that the resident's catheter tubing and drainage bag were repeatedly found resting on or dragging along the floor, both in the resident's room and in the hallway. Staff were observed rehanging the tubing and bag, but the issue persisted, with the tubing continuing to come into contact with the floor and being stepped on by the resident. Multiple staff members acknowledged having seen the tubing on the floor and identified concerns about cleanliness and the potential for the catheter to be pulled. Facility policy required that catheter tubing and drainage bags be kept off the floor and that appropriate services and treatment be provided to help restore or improve bladder function. Despite these policies, the facility did not implement a toileting plan or bladder training for the resident with incontinence, nor did it consistently ensure that catheter tubing and drainage bags were kept off the floor for the resident with a suprapubic catheter.