Failure to Provide Proper Catheter Care, Timely Documentation, and Physician Notification Resulting in Resident Harm
Penalty
Summary
The facility failed to provide proper care and treatment for a resident with an indwelling Foley catheter, resulting in significant harm. The resident, who had diagnoses including benign prostatic hyperplasia, urinary retention, and type 2 diabetes, was cognitively intact and admitted with a Foley catheter in place. Over several days, staff observed and documented blood in the resident's brief and at the tip of the penis, swelling in the thigh, decreased urine output, and a distended catheter bag. Despite these findings, there was a lack of timely and accurate documentation, and significant changes in the resident's condition were not communicated to the physician as required by facility policy. Multiple staff interviews revealed that the resident's catheter bag was repeatedly found to be overfilled, sometimes described as the size of a football, and not emptied during overnight shifts. Certified Nurse Aides reported these findings to nursing staff, but there was no evidence of appropriate follow-up or documentation. Additionally, there were instances where staff were instructed to document care tasks that had not been performed, and late entries were made in the medical record up to a month after the events occurred. The facility's Director of Nursing and other staff acknowledged issues with delayed documentation, lack of investigation, and failure to notify the physician of significant changes, including blood in the urine and decreased output. The resident ultimately experienced worsening symptoms, including abdominal pain, vomiting, confusion, and neurological changes, leading to emergency transfer to the hospital. Hospital records confirmed a diagnosis of ruptured bladder, urinary tract infection, and septic shock. The facility lacked effective catheter care policies at the time of the incident, and there was no documentation of required monitoring such as weights and leg measurements, despite physician orders. The cumulative failures in care, documentation, and communication directly contributed to the resident's decline and subsequent death.