Failure to Document and Assess Foley Catheter Placement Resulting in Urethral Trauma
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral infarction, cognitive communication deficit, benign prostatic hyperplasia, and dysuria experienced improper foley catheter care. The facility failed to document the placement of a new foley catheter and did not complete follow-up assessments after a change in urine characteristics was observed. The catheter was inserted by a nursing student under supervision, but neither the student nor the supervising nurse documented the procedure in the resident's medical record. The physician's order for the catheter change did not specify the type, size, or balloon fluid amount, and there was no documentation of the resident's tolerance, urine return, or urine color at the time of insertion. After the catheter change, the resident exhibited signs of complications, including low urine output and red-colored urine, but there was no documentation that the physician was notified of these changes. Later, the resident complained of abdominal pain, and blood was noted in the catheter bag. The resident was subsequently sent to the emergency room, where it was determined that the catheter had been incorrectly placed, resulting in urethral trauma and urinary obstruction. The hospital found the catheter balloon had been inflated in the urethra rather than the bladder, causing a traumatic injury and significant hematuria. The care plan for the resident did not include interventions to prevent pulling on the catheter, despite observations of the resident handling the catheter bag. Facility policy required documentation of catheter size, balloon size, and resident tolerance, but these were not followed. The lack of proper documentation, assessment, and follow-up after the catheter change directly contributed to the resident's injury and subsequent hospitalization.