Failure to Ensure Staff Competency in Nephrostomy Tube Care
Penalty
Summary
Licensed nurses and CNAs failed to demonstrate appropriate competencies in caring for a resident with a nephrostomy tube, resulting in two separate incidents where the tube became dislodged. The resident, who had a history of urinary tract infection and hydronephrosis, required substantial assistance with mobility and hygiene. On both occasions, the nephrostomy tube was found dislodged, with urine leaking from the insertion site and the resident's back wet, necessitating transfer to an acute care hospital for evaluation and reinsertion of the tube. Interviews and record reviews revealed that neither the CNAs nor the licensed nurses had received specific training or skills checks related to nephrostomy tube care prior to the incidents. Several CNAs confirmed they had not been trained on how to care for residents with nephrostomy tubes, and the Director of Staff Development acknowledged that skills evaluations for nephrostomy tube care were not conducted at the time of the resident's admission. The facility's own policy required competency evaluations when new procedures or equipment were introduced, but this was not followed in the case of nephrostomy tube care. Observations and interviews with the resident and family member indicated that the nephrostomy tube had not previously become dislodged at home, and the resident expressed concerns about staff awareness and handling of the tube during care activities such as turning and repositioning. The lack of staff competency assessment and training directly contributed to the improper handling of the nephrostomy tube, leading to its repeated dislodgement and the need for hospital intervention.