Failure to Monitor and Document Catheter Care Leading to Resident Hospitalization
Penalty
Summary
A resident with chronic kidney disease, obstructive and reflux uropathy, and benign prostatic hyperplasia was not properly monitored or cared for in relation to their indwelling urinary catheter. The facility failed to monitor for catheter obstruction, did not document physician-ordered urinary output every shift, and did not perform required catheter changes every 30 days or as needed. Documentation was missing for multiple shifts regarding urine output, and there was no record of catheter changes for several months, despite physician orders and facility policy requiring these actions. The resident's care plan identified high risk for urinary tract infection due to catheter use and included interventions such as monitoring intake and output, observing for signs of infection, and changing the catheter and drainage bag per physician orders. However, nursing progress notes and treatment administration records showed gaps in documentation of urine output and catheter changes. Staff interviews revealed that changes in the resident's condition, such as decreased activity, reduced urine output, and changes in urine color, were either not reported to the physician or not documented. The LPN responsible did not notify the physician of the resident's decline, and abnormal lab results were not promptly communicated to the physician, resulting in delayed treatment. The resident was eventually sent to the emergency room after exhibiting severe symptoms, including lethargy, hypotension, and purulent drainage from the catheter. Hospital records indicated the resident had acute renal failure, bladder obstruction, complicated urinary tract infection, and severe dehydration. The hospital staff noted poor catheter care, excoriation, and lack of cleanliness around the catheter site. The facility's failure to follow physician orders, monitor and document catheter care, and respond to changes in the resident's condition led to a significant decline in the resident's health and subsequent hospitalization.