Failure to Provide Timely Catheter Care and Notify Physician of Changes in Condition
Penalty
Summary
A resident with multiple complex medical conditions, including heart failure, bilateral leg amputations, obesity, diabetes with polyneuropathy, and neurogenic bladder, was admitted to the facility and received hospice services. The resident was dependent on staff for all activities of daily living and had an indwelling catheter in place. The care plan included monitoring for signs and symptoms of urinary tract infection (UTI) and ensuring catheter patency and urinary output every shift. Despite these interventions, documentation revealed that the resident exhibited symptoms of a possible UTI, such as cloudy and foul-smelling urine, increased confusion, and agitation. A urine sample was collected for urinalysis and culture, but there was no timely follow-up or documentation of the results, and neither the primary care physician nor hospice was notified promptly of the findings, which later showed significant bacterial growth requiring antibiotic treatment. On a separate occasion, the resident was found by staff to have removed her indwelling catheter, resulting in visible blood and blood clots in her brief and on the bed. The catheter, with an inflated balloon, was observed lying on the mattress. Despite the resident's change in condition and the presence of trauma, the nurse on duty did not immediately assess or address the situation, citing workload and staffing shortages. The nurse delayed reinsertion of the catheter, waiting for hospice staff to arrive, and did not notify the primary physician of the catheter removal. When hospice staff attempted to reinsert the catheter, proper infection control procedures were not followed, and the catheter was not successfully placed on the first attempt. The resident subsequently removed the catheter again, and there was continued delay in assessment and notification of the physician. Throughout these events, there was a lack of timely assessment, intervention, and communication with the primary care physician and hospice regarding significant changes in the resident's condition, including catheter removal, signs of infection, and laboratory results. The facility failed to ensure appropriate catheter care, prompt response to changes in condition, and effective communication, which affected the resident directly and had the potential to impact other residents with indwelling catheters.