Failure to Follow Professional Standards During Indwelling Catheter Care Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident with a chronic indwelling urinary catheter received care and treatment in accordance with professional standards of practice. The facility's policy required staff to document specific details after catheter insertion, including the date and time, catheter size and type, amount of sterile water used, urine characteristics, any complications, practitioner notifications, prescribed interventions, and patient teaching. However, documentation and care practices did not consistently meet these standards during the resident's stay. The resident, who had a history of bladder cancer, chronic catheter use, and was on anticoagulant therapy, experienced multiple episodes of hematuria and bleeding associated with catheter changes. After a catheter change, the resident developed significant bleeding from the penis, which continued despite removal and reinsertion of the catheter. The provider noted that the bleeding was most likely due to trauma from incorrect catheter insertion. The resident subsequently developed symptoms of infection, including fever, flank pain, and low oxygen saturation, and was diagnosed with a urinary tract infection and likely pyelonephritis. Despite ongoing monitoring and interventions, the resident's condition worsened, with continued bleeding, pain, and the development of acute blood loss anemia. The resident was eventually transferred to the hospital, where a urethral tear and laceration were confirmed, and a blood transfusion was required. Staff interviews confirmed awareness of the bleeding and complications following the catheter change, and documentation did not consistently reflect adherence to professional standards for catheter care and monitoring.