Failure to Provide Appropriate Catheter Care and Adhere to Physician Orders
Penalty
Summary
A deficiency occurred when a male resident with a history of autistic disorder, hypertension, urinary retention, recurrent urinary tract infections (UTIs), and diabetes mellitus type II did not receive appropriate catheter care as ordered. The resident had an indwelling Foley catheter with physician orders specifying monthly changes and routine catheter care every shift. Documentation showed that the Foley catheter was not changed as ordered on two consecutive months, despite being signed off as completed by medication aides (MAs) who later admitted they did not perform the task and that it was outside their scope of practice. The care plan for the resident did not include interventions for catheter care, diabetes, or hypertension at the time of the incident. The resident was subsequently transferred to the emergency room after staff noted fever, lethargy, decreased urine output, and low blood pressure. Hospital records indicated the resident was diagnosed with a urinary tract infection, possible sepsis, acute kidney injury, and pneumonia. The Foley catheter was found to have brown urine with pus and was replaced in the emergency room. Interviews with staff revealed a lack of clarity regarding responsibilities for catheter changes, with MAs signing off on tasks they did not perform and failing to notify licensed nurses of the outstanding orders. The DON confirmed that MAs were not permitted to change Foley catheters and that the resident's catheter change orders were not followed as required. Further review of facility documentation and interviews with the nurse practitioner and medical director highlighted discrepancies in the understanding and implementation of catheter care orders. The medical director expressed disagreement with the monthly change order, but the facility had not clarified or updated the order prior to the incident. The lack of proper documentation, failure to follow physician orders, and absence of a comprehensive care plan for catheter management contributed to the resident's hospitalization and the identification of an Immediate Jeopardy situation by surveyors.