Improper Urinary Catheter Insertion Resulting in Resident Pain and Bleeding
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to perform urinary catheter placement according to the facility's established standards of practice. The facility's procedures required that catheters be inserted by licensed nurses under physician orders, with specific steps for sterilization, lubrication, and gentle insertion, and clear instructions not to force the catheter if resistance was met. In this incident, the LPN attempted to insert a urinary catheter for a resident with neurocognitive disorder, dementia, and a history of vancomycin-resistant enterococci (VRE) in the urine, but was unsuccessful and left the resident in pain with blood present on the bed and in the resident's brief. The resident, who was moderately cognitively intact according to the most recent assessment, reported to another nurse that the catheterization attempt was painful and resulted in bleeding. The nurse who discovered the situation noted the absence of a catheter bag, the presence of blood, and that the resident stated the LPN had tried but failed to insert the catheter, causing pain. The incident was further corroborated by a police report and statements from staff, indicating that the LPN left the room after the unsuccessful attempt without seeking assistance or notifying supervisory staff as required by protocol. Following the event, the resident was transported to the hospital for evaluation due to pain and bleeding, though no trauma was ultimately found. The investigation determined that the LPN appeared to be impaired at the time of the incident and did not follow proper procedures for catheter insertion, including not seeking help when encountering difficulty. The facility's leadership confirmed that the LPN should not have attempted the procedure under those circumstances and failed to follow expected protocols.