Failure to Provide Timely Catheter Care and Physician Notification
Penalty
Summary
The facility failed to provide appropriate care and timely assessment for a resident with an indwelling Foley catheter. The resident, who had diagnoses including neoplasm of the kidney, obstructive and reflux uropathy, and benign prostatic hyperplasia, had physician orders for weekly changes of the urinary drainage bag and as-needed catheter changes for obstruction or dislodgement. Observations revealed the resident had a Foley catheter and drainage bag in place with dark yellow, cloudy urine containing visible sediment and a foul odor. The resident reported the catheter and drainage bag had not been changed in over a month, and staff attributed moisture in the resident's diaper to leakage from the catheter insertion site. The LPN confirmed the presence of sediment, an old and discolored drainage bag, and cloudy, foul-smelling urine, but there was no evidence in the medical record that the catheter was assessed in a timely manner, the physician was notified of the foul-smelling urine, or that the change in condition was documented. Further review showed that although the treatment administration record indicated weekly catheter changes, these were not performed as ordered. The Assistant Director of Nursing and Director of Nursing both confirmed that staff were expected to follow physician orders, assess for changes in condition, and document findings, including using the SBAR process for communication. However, there was no documentation of leakage, symptoms of urinary tract infection, or physician notification. Facility policy required monitoring and documentation of urine characteristics and prompt notification of abnormal findings, but these procedures were not followed for this resident.