Failure to Monitor and Provide Appropriate Nephrostomy Tube Care Resulting in Hospitalization and Infection
Penalty
Summary
The facility failed to provide appropriate care and monitoring for nephrostomy tubes for two residents, resulting in hospitalization and infection. For one resident with a history of hydronephrosis, kidney stones, and recurrent infections, there was a lack of consistent documentation and monitoring of nephrostomy tube output and exit site care. Orders for dressing changes and output monitoring were inconsistently followed, with multiple missed or undocumented dressing changes and no regular recording of nephrostomy output. The resident experienced repeated dislodgement of the nephrostomy tube, redness and drainage at the exit site, and ultimately developed a severe kidney infection with ESBL-producing E. coli, requiring hospitalization and intravenous antibiotics. Hospital records indicated the nephrostomy tube stopcock was in the off position, leading to a large volume of purulent fluid accumulation, which was not documented or addressed in the facility's records. For the second resident, who had diagnoses including urinary tract infection, bacteremia, and hydronephrosis, there was also a lack of a care plan for nephrostomy care and inconsistent documentation of nephrostomy output. Despite orders to empty and record the nephrostomy bag output every shift, there were numerous shifts with zero output documented and one shift with no documentation at all. Observations revealed confusion among staff regarding the correct positioning of the nephrostomy tube stopcock, with some staff unable to confidently determine whether the tube was draining properly. The resident reported minimal output from the nephrostomy tube, and staff interviews confirmed uncertainty about the correct procedures for nephrostomy care. Throughout the review, staff interviews revealed a lack of knowledge and training regarding nephrostomy tube management, including the correct positioning of stopcocks and the importance of securing and monitoring the tubes. There was also evidence of staff documenting care that was not performed, lack of follow-up on missed or refused treatments, and insufficient communication and documentation regarding changes in resident condition or hospital transfers. Facility policy required care consistent with professional standards, including regular assessment, documentation, and prompt reporting of abnormalities, but these standards were not met for the residents reviewed.