Failure to Provide Timely Catheter Care and Prevent UTI
Penalty
Summary
Staff failed to provide appropriate treatment and services to prevent potential urinary tract infections for a resident with an indwelling catheter. The resident, who had diagnoses including dementia with agitation, urinary retention, and chronic kidney disease, required extensive assistance and had severely impaired cognition. The care plan directed staff to perform catheter care every shift, keep the catheter bag and tubing below the level of the bladder, and observe for pain, discomfort, and signs of infection. However, the care plan did not specify the frequency for emptying the catheter bag. Observations revealed that the resident's catheter bag and tubing were visibly full of urine on multiple occasions throughout the day, including during lunch and later in the afternoon. Staff did not empty the catheter bag until after the resident was transferred back to bed, despite the bag being full for an extended period. Interviews with staff confirmed that the catheter bag should be emptied at least every shift and as needed, and that allowing the bag and tubing to become overfilled could result in urine backing up into the bladder, causing pain or infection. The facility's policy required regular emptying of the catheter bag to maintain unobstructed urine flow and prevent infection. Despite this, the resident's catheter bag was not emptied as required, and the care plan lacked clear instructions on the frequency of emptying. This failure to follow established protocols and physician orders resulted in the resident being placed at risk for complications and infection.