Failure to Ensure Proper Catheter Care and UTI Prevention
Penalty
Summary
A deficiency was identified when a resident with a suprapubic Foley catheter was observed to have cloudy, amber-colored urine with visible sediments in the drainage bag. During the observation, a Licensed Vocational Nurse (LVN) acknowledged the presence of these signs and stated that the catheter needed to be irrigated. The resident's medical record indicated diagnoses including hemiplegia, obstructive and reflux uropathy, and chronic kidney disease. The resident was noted to have no cognitive impairment and required substantial assistance with activities of daily living. A physician's order was in place to irrigate the Foley catheter with 30ml as needed for maintenance. Further interviews revealed that facility protocol required daily assessment of the Foley catheter, and that any observation of amber urine, sediments, or cloudiness should prompt a change of condition report, physician notification, and urine specimen collection. The Director of Nursing confirmed that Foley catheters must be assessed every shift and that the physician should be notified if sediments are observed. The failure to follow these procedures resulted in the resident not being free from signs of urinary tract infection, as evidenced by the observed condition of the urine and drainage bag.