Failure to Provide Comprehensive Suprapubic Catheter Care Resulting in Sepsis and Hospitalization
Penalty
Summary
A deficiency occurred when facility staff failed to develop and implement comprehensive and individualized care and interventions for a resident with a suprapubic catheter. The resident, who had a history of neurogenic bladder, diabetes, hypertension, and other chronic conditions, had a physician order for suprapubic catheter care every shift and monthly catheter changes. Despite these orders, there was no evidence that a care plan was developed at the time of catheter placement, and documentation showed repeated missed catheter care and tubing checks across several months. Staff interviews revealed that catheter care was not consistently performed due to staffing shortages, and some staff were unaware of or misunderstood the physician's orders regarding catheter changes, with some believing the order referred only to the catheter bag rather than the catheter itself. The resident's medical records indicated that catheter care and monthly changes were not documented as completed on multiple occasions, and there was no documentation of the resident refusing care or of the physician being notified about missed catheter changes. Additionally, there was no monitoring or documentation of urinary output or urine appearance prior to the resident's acute change in condition. Staff interviews confirmed that the suprapubic catheter had not been changed as ordered, and some staff admitted to not having received training on how to perform the procedure. The resident's care plan addressing the suprapubic catheter was not initiated until several months after placement, and interventions to monitor for complications were not implemented in a timely manner. As a result of these failures, the resident developed a severe urinary tract infection that progressed to sepsis and acute kidney injury, requiring hospitalization and intensive care. Hospital records documented grossly purulent urine, obstructive kidney stones, and the need for surgical intervention, including catheter exchange and stent placement. The lack of adherence to physician orders, inadequate documentation, and insufficient staff knowledge and training directly contributed to the resident's acute medical deterioration.
Removal Plan
- Resident #05 was transferred to the hospital and remained in the hospital.
- An audit of all current residents was completed by the DON for any residents with a suprapubic catheter. No other residents noted with a suprapubic catheter. Resident #09 was identified to have an order for an indwelling urinary catheter (Foley). Resident #09 was seen by the Nurse Practitioner.
- An investigation was completed by the DON of why this error occurred in order to implement corrective actions.
- RDCO #1022 reviewed facility policies including the Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures to ensure they were comprehensive, and no changes were needed prior to staff education.
- RDCO #1022 provided education to the DON on Physician Orders policy, Suprapubic Cath Care and Suprapubic Cath Replacement procedures.
- Education was provided in person or via phone to all current licensed nurses by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The education included following physician orders regarding catheters including catheter care (video was given on steps for suprapubic catheter replacement), along with the suprapubic catheter care and replacement procedure. In addition, staff were educated if they were unable to complete this task for the day as ordered, they were to report to the DON/ADON and they would assist on how to get the task completed. The DON followed up with the nurses after the education to ensure there were no unanswered questions related to the education.
- All current Certified Nurses Assistants (CNAs) were educated by the DON on catheter care for Foley catheters using the facility Catheter Care policy. A video was provided on how to do catheter care. The CNA staff were educated if they were unable to complete this task as ordered for the day they were to report to the DON/ADON and they would assist in how to get the task completed. The DON followed up with CNAs after the education to ensure there were no unanswered questions related to the education.
- The Medical Director was notified by the DON of the Immediate Jeopardy (IJ) concern involving Resident #05. An Ad-hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with Medical Director, DON, Administrator, and RDCO #1022. The IJ was reviewed, the reason for the IJ, and the facility abatement plan.
- The Administrator provided contracted staffing agencies education related to catheter care. Education would be added for the staff to review prior to picking up a shift. The DON/designee would ensure agency staff reviewed education by contacting them once they had arrived at the facility and getting a verbal acknowledgement they have reviewed.
- The facility implemented a plan for all new staff to be verbally educated on Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures, what to do if you do not know how to change a catheter, following physician orders by the DON/designee during new hire orientation.
- The DON/ADON would review physician orders daily and would ensure if there were any new suprapubic catheter orders that the care and changing orders were in place and being followed. The DON/ADON would review residents with suprapubic catheters and would review catheter orders to ensure they were accurately documented when completed by going in and checking if the care and or catheter had been changed per order.