Failure to Assess and Intervene for Catheter-Related Change in Condition
Penalty
Summary
A deficiency occurred when a resident with a history of Parkinson's disease, acute kidney failure, obstructive and reflux uropathy, BPH, and recurrent urinary tract infections, who was dependent on an indwelling Foley catheter, did not receive appropriate assessment and intervention for changes in catheter output and condition. Over a period of several days, the resident's catheter was noted to be draining blood with minimal to no urine output, and the resident exhibited signs of discomfort and pain, including abdominal distension and moaning. Despite these changes, there was a lack of timely documentation, assessment, and escalation to medical providers or hospice, as required by facility policy and professional standards. Multiple staff members, including LVNs and CNAs, observed and were aware of the presence of blood in the catheter and the resident's discomfort, but interventions were either not documented or not performed according to protocol. Communication among staff was inconsistent, with information about the resident's condition being passed verbally from shift to shift without proper documentation or notification to the physician or hospice nurse. The hospice nurse was not informed of the ongoing issues until several days after the initial change in condition, and the resident was not sent to the emergency room until the situation had significantly deteriorated. Upon eventual transfer to the hospital, the resident was diagnosed with sepsis, acute urinary retention, complicated UTI associated with the indwelling catheter, and dehydration. The hospital records indicated that the catheter was not properly draining due to displacement, and the resident's symptoms were managed with IV medication in inpatient hospice care, where the resident later expired. The facility's failure to assess, document, and intervene appropriately in response to the resident's change in condition led to the identification of an Immediate Jeopardy situation.