Failure to Monitor Nephrostomy Output and Adhere to Catheter Care Protocols
Penalty
Summary
Facility staff failed to consistently monitor and document nephrostomy tube output for a resident with bilateral nephrostomy tubes. According to facility policy and physician orders, nephrostomy output was to be measured and recorded every eight hours, with separate documentation for each kidney. However, review of the resident's medical records revealed numerous gaps in documentation, indicating that staff did not reliably monitor or record the required output. The Director of Nursing confirmed these omissions and stated that it was her expectation for staff to document nephrostomy output as ordered. In a separate incident, staff did not adhere to infection control protocols during urinary catheter care for another resident. The facility's policy required the use of enhanced barrier precautions, including gown and gloves, during high-contact care activities involving indwelling medical devices such as urinary catheters. During observed catheter care, a CNA failed to wear a gown and did not cleanse the catheter tubing as required by the facility's performance skills guidelines. The CNA acknowledged these lapses during the observation. The Director of Nursing and Infection Preventionist both confirmed that staff are expected to use appropriate PPE and follow catheter care procedures. Both deficiencies involved residents with significant medical histories, including chronic kidney disease, urinary tract infections, and indwelling urinary devices. The failures were identified through observation, interview, and record review, and were confirmed by facility leadership. These lapses represent noncompliance with facility policies and physician orders regarding the care and monitoring of residents with nephrostomy tubes and urinary catheters.