Failure to Provide Timely Catheter Care and Maintain Resident Dignity
Penalty
Summary
A resident with neuromuscular dysfunction of the bladder, paraplegia, osteomyelitis, diabetes, and a right below-knee amputation, who was dependent on staff for toileting and had an indwelling catheter, experienced a failure in care when his foley catheter began leaking and was not draining properly. The resident had physician orders for the catheter to be flushed every shift and as needed, and to change the catheter if there was leakage, blockage, or sedimentation. On the day of the incident, the resident was found soaked in urine, with both his bed linen and t-shirt wet, and he requested assistance from an LVN to change his catheter. Despite the resident's request and the presence of standing orders, the LVN did not flush or change the catheter, instead telling the resident that she wanted to call the physician first. The resident, not wanting to wait and still sitting in urine, called 911 for assistance. EMS staff who arrived observed the resident covered in urine from his mid-chest down. The LVN did not provide any catheter care or hygiene assistance prior to the resident's transport to the hospital. Upon return from the hospital, the resident reported the incident to another LVN, who did not escalate the issue. The Director of Nursing confirmed that this was the first time she was made aware of the incident. The facility's policy requires staff to treat residents with kindness, respect, and dignity, and to support residents in exercising their rights. The failure to provide timely catheter care and hygiene resulted in the resident being left in a urine-soaked state and ultimately being transported to the hospital for a dislodged catheter and a urinary tract infection.