Failure to Provide Timely and Complete Catheter and Wound Care, Leading to Penile Injury
Penalty
Summary
A resident with multiple complex medical conditions, including chronic kidney disease, urinary retention, and an indwelling urethral catheter, was admitted to the facility without any penile wounds. The resident required significant assistance with personal care and was dependent on staff for toileting. The care plan instructed staff to anchor the catheter tubing high on the resident's thigh to prevent pulling and reduce the risk of injury, and to monitor and report any redness or skin issues. Despite these instructions, the catheter was repeatedly found unsecured, and the resident developed redness, excoriation, and eventually an open, bleeding wound on the penis. Staff failed to provide timely and complete catheter and wound care as ordered. The resident's physician ordered zinc cream to be applied twice daily to the penile wound, but documentation shows that the cream was not available on multiple occasions, and the treatment was not consistently administered. Additionally, staff did not fully retract the resident's foreskin during perineal and wound care, resulting in incomplete cleansing and assessment of the wound. There was also a lack of proper wound documentation, including measurements and drainage assessment, and the facility was unable to provide records of ongoing wound monitoring. Infection control practices were not followed during wound care. A CNA and an RN both failed to change gloves or perform hand hygiene between cleansing the wound and applying the prescribed zinc cream, and the RN applied the cream with contaminated gloves. The catheter remained unsecured during care, and staff acknowledged not following proper procedures. The DON confirmed that the penile wound was caused by constant pulling of the catheter and that the facility should not have run out of zinc oxide. The resident's wound worsened during the stay, and the facility could not provide adequate documentation of wound assessment or monitoring.