Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including end-stage renal disease and Alzheimer's disease, was not provided with appropriate urinary catheter care. After a nurse inserted a 16 French indwelling urinary catheter, there was no urine return observed. Despite this, the clinical record did not show that the catheter placement was reassessed prior to the discovery of blood in the catheter tubing and bag. The facility's policy required that the catheter be inserted until urine flow was observed and not to force entry if resistance was met. Later, a medical assistant reported the presence of bright red blood in the resident's catheter bag, prompting emergency transport to the hospital. Imaging at the hospital revealed that the catheter balloon had been inflated within the penile urethra, rather than the bladder. The lack of documentation regarding reassessment of catheter placement after the absence of urine return contributed to the deficiency in providing appropriate catheter care.