Failure to Monitor and Assess Foley Catheter Care Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate care and monitoring for a resident with quadriplegia and an indwelling Foley catheter. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a history of acute renal failure, dementia, and dysfunctional bladder. Over a 24-hour period, the resident's urine output was significantly decreased, with only 300 ml recorded, and then zero output documented for the following shift. This decrease in urinary output was not communicated to nursing staff or the physician, and no assessment was performed for possible urinary retention or catheter obstruction. Nursing staff did not conduct assessments or monitor the resident for impaired urinary elimination or changes in urine characteristics, such as color, odor, or clarity, which could indicate a problem with the resident's urinary status. The facility's baseline care plan lacked specific interventions for assessing catheter patency, placement, or complications related to quadriplegia, such as autonomic dysreflexia. Documentation showed that CNAs were responsible for recording urine output, but there was confusion and lack of knowledge among staff regarding what constituted low output and when to notify a nurse or physician. Additionally, a CNA with medication authority signed off on nursing orders, which was outside their scope of practice. The resident was eventually found unresponsive and in respiratory distress, with vital signs indicating a critical condition. Upon transfer to the hospital, the resident was found to have a distended bladder containing 2000 ml of bloody urine with pus, bilateral hydronephrosis, and was diagnosed with severe sepsis, acute respiratory failure, and myocardial infarction. Staff interviews revealed a lack of training and knowledge regarding the care of residents with indwelling catheters and those with special needs such as quadriplegia. The failure to monitor, assess, and communicate changes in the resident's urinary status directly led to the resident's hospitalization and critical illness.
Removal Plan
- Education for all nurses and CNAs on daily catheter care, as well as monitoring and reporting of urinary output, was completed by the DON or designee.
- Nurses were educated on how to perform bladder assessments for residents with indwelling catheters, with a special focus on residents unable to communicate or who are paralyzed.
- All residents with indwelling catheters were audited for their last catheter change date and ensured accurate physician's orders were obtained for the next catheter change.
- The electronic medication administration record (eMAR) was reviewed to ensure accurate orders were in place, including those for catheter care, urinary output monitoring, and catheter replacement.
- All residents with indwelling catheters were assessed by the DON for bladder fullness to ensure proper catheter drainage.
- An as needed catheter change physician's order was added for another identified resident affected by the deficient practice.
- A shift evaluation for residents with dwelling catheters was implemented, including assessments of bladder status, urine output, potential blockages, and urine characteristics, to be conducted by floor nurses and documented in the eMAR.
- Abnormal findings from the floor nurse will be reported to the director of nursing and the on-call physician.
- All new admissions, readmissions, and newly ordered indwelling Foley catheters will be audited by the DON or designee to ensure catheter insertions are completed in accordance with physician's orders.
- All new admissions with indwelling catheters will be audited by the DON or designee to confirm the presence of appropriate physician orders and nursing interventions for daily catheter care.
- The audit will be completed by the director of nursing or designee.