Failure to Implement Physician-Ordered Genital Elevation for Catheter-Associated Complication
Penalty
Summary
The facility failed to provide care and services consistent with professional standards and the resident's person-centered care plan regarding the management of an indwelling urinary catheter. Specifically, the facility did not adhere to a physician's order to elevate a resident's genital area after the resident developed a slit and swelling in the genital region, which was associated with the indwelling catheter. The care plan and physician's orders required elevation of the genital area to address the complication, but this intervention was not implemented in a timely manner. The resident, who had a history of urinary tract infection, urine retention, and obstructive uropathy, was dependent on staff for activities of daily living and positioning in bed. Documentation showed that the order to elevate the genital area was not transcribed or carried out until several weeks after it was given, despite ongoing skin breakdown and wound care needs. Observations confirmed that the resident's genital area was not elevated during care, and staff interviews revealed a lack of awareness and understanding of how to provide the required elevation. Nursing staff, including a CNA and a nurse, indicated they were either unaware of the intervention or believed that the use of an air mattress was sufficient, which was contradicted by the Director of Nursing. The DON clarified that an air mattress does not provide elevation to the genital area and that pillows or rolled towels should be used. The deficiency was further evidenced by the lack of documentation and implementation of the elevation order, as well as staff's lack of knowledge regarding the intervention.