Failure to Prevent and Manage UTIs in Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide necessary care and services to prevent urinary tract infections (UTIs) from developing or worsening in two residents with indwelling catheters. For one resident, the facility did not follow physician orders for a silver coated Foley catheter, failed to order and perform required laboratory tests, and did not change the catheter according to the prescribed schedule. The resident's medical records showed missed documentation of a urology appointment, lack of evidence that the ordered silver coated catheter was ever provided, and a significant gap between catheter changes. The resident experienced escalating pain, with pain levels documented as high as 10 out of 10, and there was a lack of timely assessment and documentation of vital signs and laboratory testing during a period of worsening symptoms. The resident ultimately developed a severe UTI that progressed to Fournier's gangrene and sepsis, as confirmed by hospital records, which also noted the resident had been requesting to be sent to the emergency room for several weeks prior to transfer. In the second case, another resident with a history of chronic health conditions and an indwelling catheter was prescribed a five-day course of Ertapenem for a UTI. The medication administration records showed that only three out of five doses were given, with no documentation explaining the missed doses or indicating that the provider was notified about the incomplete antibiotic course. There was also no evidence in the progress notes to account for the missed doses or any follow-up actions taken in response to the incomplete treatment. Interviews with staff revealed inconsistencies in knowledge and practice regarding catheter care, change of condition, and documentation. Some staff reported receiving only occasional in-service training, and there was a lack of demonstration-based education. Facility policies required staff to notify providers of abnormal findings and to document all relevant communications and follow-up actions, but these procedures were not consistently followed. The facility's own abuse prevention policy defined neglect as the failure to provide necessary goods and services to avoid physical harm, pain, or distress, which was reflected in the findings for both residents.