Failure to Ensure Nurse Competency for Pleurex Catheter Care
Penalty
Summary
The facility failed to ensure that a licensed nurse had the necessary knowledge and training to provide care for a Pleurex catheter for one resident. The resident, who had multiple diagnoses including an infection to the left arm, kidney failure, heart disease, irregular heart rate, COPD, type 2 diabetes mellitus, and pleural effusion, was admitted with a physician's order to have the Pleurex catheter drained on specific days of the week. The order to drain the catheter was not entered into the system until two days after the resident's admission, and documentation showed that the catheter was not drained as ordered on two scheduled days. The Director of Nursing confirmed that the nurse assigned on one of the scheduled days did not perform the procedure because they did not know how to drain the Pleurex catheter. Prior to the resident's admission, the only preparation provided was printing out the policy and procedure for the device, with no additional education or training given to the nursing staff. Nursing education on the Pleurex drainage system was not documented until over a month after the resident's admission.