Failure to Provide Appropriate Catheter Care and Timely Physician Notification
Penalty
Summary
A resident with a history of kidney stones, neuromuscular bladder dysfunction, chronic heart failure, and atrial fibrillation, who was on anticoagulant medication and had a Foley catheter, experienced inappropriate catheter care. The resident had physician orders for bladder irrigation using 0.25% acetic acid solution, but a nurse was unable to locate the prescribed solution and instead used vinegar, believing it to be equivalent. The vinegar was instilled into the resident's bladder, causing a severe burning sensation. The nurse did not clamp the catheter as ordered due to the resident's complaint but failed to document the incident or notify the physician or family about the medication error. Following the vinegar flush, the resident experienced gross hematuria (significant blood in the urine) for several days. Despite ongoing bleeding, the facility did not promptly notify the resident's physician, nurse practitioner, or urologist. Documentation shows that the nurse practitioner and urologist were only updated after several days of continued hematuria, and the urologist ultimately recommended the resident be transferred to the emergency room for evaluation. The delay in notification was contrary to the facility's policy, which required prompt reporting of significant changes in condition, such as marked differences in usual signs or symptoms, including gross hematuria. Interviews with facility staff revealed that the Director of Nursing was initially unaware of the incident and only learned about the use of vinegar from the resident's family days later. The nurse involved admitted to using vinegar due to confusion about the solutions and acknowledged not reporting the error. The facility's investigation confirmed that the incident was not reported in a timely manner, and there was a lack of staff education regarding the importance of immediate physician notification when blood is observed in a resident's urine.