Failure to Prevent Catheter-Related Urethral Injury
Penalty
Summary
A resident with a history of urinary retention and sacral wound infections was admitted with a temporary indwelling Foley catheter. The resident was cognitively intact and required ongoing medical and wound care. During the course of care, the resident developed a full-thickness wound on the penis, identified as a medical device-related injury associated with the indwelling catheter. Clinical documentation and wound care notes described the wound as having significant measurements and fresh blood drainage, with the wound bed showing 100% granulation. The injury was confirmed by both wound care staff and a physician, who attributed the trauma to the catheter. Further review and consultation with a urologist revealed that the resident had developed ventral urethral erosion, a rare but serious complication often caused by prolonged catheter tension, resulting in a partial or full-thickness wound of the urethra. The injury was significant enough to require evaluation for surgical correction. Facility leadership, including the DON and IDON, acknowledged that the injury was related to the urinary catheter and confirmed the findings with photographic evidence. The incident was discussed with the Nursing Home Administrator during the exit interview.