Failure to Provide Timely Catheter Assessment, UTI Treatment, and Adequate Incontinence Care
Penalty
Summary
The facility failed to provide timely and appropriate care for residents with indwelling catheters, urinary tract infections (UTIs), and incontinence. One resident was admitted with multiple diagnoses, including a fracture, heart failure, chronic kidney disease, benign prostatic hyperplasia, and a UTI. The resident had an indwelling catheter for pain control and mobility, which required comprehensive evaluation upon admission, weekly for four weeks, and then quarterly. However, there was no evidence of ongoing comprehensive evaluation of the catheter between late February and the end of April. The resident's catheter was eventually discontinued at his request, but the urinalysis sample obtained at that time was not sent to the lab promptly, resulting in delayed diagnosis and treatment. The resident was started on antibiotics before urine test results were available, and ultimately required two different antibiotics due to resistance patterns identified later. Additionally, the facility failed to provide adequate incontinence care for another resident who was frequently incontinent of bowel and bladder. During observed care, a CNA performed incontinence care with the blinds open, exposing the resident to potential lack of privacy. The CNA did not fully clean the resident, leaving stool on the resident's skin and on the clean incontinence product that was applied. The CNA acknowledged that the resident was not fully cleaned and stated that staff would check and clean the resident again in about 20 minutes. The Assistant Director of Nursing confirmed that the care provided was not appropriate and that the resident should not have been left soiled. Policy review indicated that indwelling catheters should be used sparingly and only for appropriate indications, with ongoing evaluation and documentation of need. The policy also required prompt identification and management of UTIs and appropriate incontinence care. The facility's failure to follow these policies resulted in delayed assessment and treatment of a UTI, inadequate catheter care, and insufficient incontinence care for the residents involved.