Failure to Provide Appropriate Catheter Care and Prevent UTI
Penalty
Summary
A deficiency occurred when a resident with a history of neuromuscular bladder dysfunction, paraplegia, diabetes, and a stage 4 pressure ulcer did not receive appropriate catheter care as ordered. The resident had physician orders for a Foley catheter, including instructions to flush the catheter every shift and as needed, and to change the catheter in cases of leakage, blockage, or sedimentation. On the day of the incident, the resident's catheter was leaking and not draining properly, resulting in the resident being soaked in urine and experiencing a full, tender bladder. Despite the resident's request for assistance, the assigned LVN did not flush or change the catheter as ordered, nor did she clean the resident or address the leakage. The LVN stated she intended to call the physician before taking action, even though standing orders were in place to change the catheter for leakage. She also reported not having previously changed a catheter at the facility and only working PRN. The resident, after not receiving help, called 911 and was transported to the emergency room, where it was found that the catheter was dislodged and a UTI was present. EMS personnel and another LVN confirmed the resident was covered in urine, the catheter was leaking, and the tip was improperly positioned in the urethra rather than the bladder. Facility policy required replacing the catheter and collecting system using aseptic technique in cases of leakage or system compromise, and to observe and report complications such as urinary retention or infection. The DON confirmed that the nurse should have flushed or changed the catheter per orders and policy. The incident was not documented accurately in the nursing notes, and the DON was not made aware of the situation until after the resident filed a grievance.