Failure to Provide Sterile Nephrostomy Site Care per Orders and Policy
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, professional standards of practice, and the comprehensive care plan for a resident with nephrostomy tubes. The resident, an older adult with a history of hydronephrosis, chronic kidney disease, urinary tract infection, and type 2 diabetes, had physician orders for twice-daily sterile dressing changes to both nephrostomy sites. However, observations on two consecutive days revealed that no dressings were present at either nephrostomy site, and staff interviews confirmed that the ordered dressing changes were not performed on those days. Documentation in the Treatment Administration Record (TAR) indicated that dressing changes had been signed off as completed by an LVN, but the LVN admitted in interviews that she had not performed the dressing changes on the specified days and had signed off regardless. Further, the LVN and other nursing staff were unaware that sterile technique was required for these dressing changes, as specified in the facility's policy. Multiple staff, including the ADON and RN, reported not receiving training or in-services on nephrostomy care or the need for sterile technique, and the facility's in-service records for the past six months confirmed the absence of such training. The DON acknowledged that it was her expectation for staff to use sterile technique for nephrostomy dressing changes and that she had not ensured the dressing was applied after her assessment. The physician and administrator both stated that care should be provided per orders and policy, and that failure to do so could increase the risk of infection or deterioration of the stoma site. The resident herself reported that staff only applied lotion to her back and did not change the dressings as ordered.