Failure to Investigate Catheter-Related Injury
Penalty
Summary
The facility failed to thoroughly investigate a treatment-related injury involving a resident with quadriplegia and neuropathic bladder who experienced a traumatic Foley catheter placement. The resident was admitted with significant medical needs and was cognitively intact at the time of the incident. On the night the catheter was changed, the resident later developed symptoms of infection, including nausea and elevated temperature, and subsequently became nonresponsive, requiring emergency hospitalization for septic shock. The facility's investigation did not include documentation identifying the staff member who performed the catheter placement or a witness statement from that staff member. Interviews with staff revealed uncertainty about who completed the procedure, and attempts to contact the suspected staff member were unsuccessful. The Director of Nursing Services acknowledged that the investigation should have included a witness statement from the staff involved.