Failure to Provide Nephrostomy Tube Care per Standards
Penalty
Summary
The facility failed to provide appropriate nephrostomy care and services consistent with professional standards of practice for a resident with multiple urological diagnoses, including obstructive and reflux uropathy, chronic kidney disease, and hydronephrosis. Upon observation, the resident's nephrostomy insertion site dressing was found to be not intact and had not been changed since before admission, as confirmed by the resident, who stated the last dressing change occurred at the hospital. The resident reported asking a nurse to change the dressing but was told there were no orders to do so. The urine in the nephrostomy bag appeared serosanguinous. Review of the medical record revealed no physician orders related to nephrostomy tube care, and the care plan did not include specific interventions for dressing changes or tube flushing. During interviews, the DON was unable to describe the care provided for the nephrostomy tube and acknowledged that orders for care had not been obtained. The facility's care plans addressed infection prevention and catheter care in general terms but did not specify nephrostomy tube management. Professional standards recommend changing the nephrostomy dressing at least every seven days or sooner if soiled or wet, which was not followed in this case. The lack of physician orders and failure to provide timely dressing changes led to the deficiency in care for the resident's nephrostomy tube.