Failure to Provide Appropriate Catheter Care and Timely UTI Management
Penalty
Summary
The facility failed to provide appropriate and hygienic catheter care, monitor urinary catheter output, and timely treat symptoms of urinary tract infection (UTI) for three residents. For one resident with a history of multidrug-resistant infections and moderate cognitive impairment, staff did not consistently change the urinary catheter as ordered, with a gap of several months between documented changes. There was also a lack of routine monitoring and documentation of urinary output. Staff did not follow Enhanced Barrier Precautions (EBP), as they failed to wear gowns during high-contact care activities, including catheter care and transfers, despite posted signage and available PPE. Catheter care was not performed according to protocol, with incomplete cleaning of the catheter tubing. These failures led to the resident developing urinary retention, UTI, urosepsis, acute kidney injury, and hydronephrosis, requiring hospitalization and urinary stent placement. Another resident was observed with urinary catheter tubing dragging on the floor during transfer, and the collection bag was held above the level of the bladder, causing urine to drain back toward the bladder. The clip intended to keep the tubing off the floor was not used. Staff again did not wear gowns during high-contact care, despite EBP signage. The resident's urine was noted to be cloudy with sediment, and subsequent urine cultures revealed significant bacterial growth, including ESBL E. coli and vancomycin-resistant Enterococcus faecalis. A third resident experienced frequent UTIs, and there were delays in obtaining and processing urine samples after symptoms were reported. Documentation showed a lag of several days between the onset of symptoms and the collection and processing of urine samples, with no evidence that the initial sample was sent to the laboratory. Orders for antibiotics were not received until nine days after symptom onset, and there was a lack of documentation regarding the handling of urine specimens. These actions and inactions contributed to the deficiencies identified in the care of residents with urinary catheters and UTIs.