Failure to Prevent Recurrent UTIs and Timely Reassess Catheter Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and services to prevent urinary tract infections (UTIs) for a resident with an indwelling urinary catheter. The resident, who had multiple diagnoses including neurogenic bladder, sacral pressure ulcer, and chronic kidney disease, was admitted with a urinary catheter and experienced ongoing discomfort and recurrent UTIs. Despite repeated complaints of pain and discomfort related to the catheter, as well as multiple documented UTIs treated with antibiotics, there was no timely or appropriate assessment for the removal of the catheter. Observations and interviews revealed that the resident repeatedly expressed discomfort and requested removal of the catheter, but staff did not act on these requests until much later. The infectious disease nurse practitioner and infection prevention nurse both indicated that there was no documented outreach to the physician to consider discontinuing the catheter, and the attending physician confirmed that there had not been any prior attempt to reassess or remove the catheter before it was eventually dislodged and removed. The resident had been treated for UTIs on several occasions, with the same bacteria recurring, and the infectious disease nurse practitioner noted that improper cleaning and contamination from a sacral wound may have contributed to the infections. Facility policies required ongoing assessment and review of residents with indwelling catheters, especially in cases of recurrent infection, but these procedures were not followed. The lack of timely reassessment and failure to consider catheter removal contributed to the resident experiencing four UTIs during her stay, with ongoing discomfort and repeated antibiotic use.