Failure to Provide Appropriate Catheter Care and Prevent UTI
Penalty
Summary
The facility failed to provide appropriate interventions for a resident with an indwelling urinary catheter, as evidenced by a lack of response to decreased or absent urinary output over multiple shifts. The resident, who had moderate cognitive impairment and a physician's order for as-needed catheter flushes in the event of clogging or dysfunction, consistently had recorded outputs of 100mL or less per shift, including several instances of 0mL output. Despite these findings, there was no documentation in the Medication Administration Record, Treatment Administration Record, or progress notes indicating that the as-needed catheter flushes were performed during the period in question. Staff interviews confirmed that the expectation was to perform a catheter flush when output was 100mL or less per shift, and that such interventions should be documented. Nursing staff acknowledged that they would have performed a flush under these circumstances, and the Director of Nursing stated that nurses should be notified of decreased output and should investigate further. The resident was ultimately hospitalized for acute respiratory failure related to sepsis secondary to a urinary tract infection. Facility policy required preventive measures for infection control in residents with urinary catheters, including changing catheters per orders.