Failure to Provide Proper Catheter and Nephrostomy Care and Respond to Abnormal Urine
Penalty
Summary
The deficiency involves failures in catheter and nephrostomy care, including not implementing care plan interventions, not following physician orders, and not assessing and responding to abnormal urine. One resident with neuromuscular bladder dysfunction and a diagnosis including UTI had an indwelling catheter with tubing that was notably cloudy, with chunks of purulent substance and heavy sediment observed in the urine. The catheter bag was undated, and the resident was unsure when it was last changed. The MAR contained an order to change the urinary bag as needed when clinically appropriate every 8 hours, but there was no documentation of any bag changes. When questioned, an LPN acknowledged the discoloration and sediment, confirmed the bag was not dated, and stated that the physician had not been notified of the abnormal urine. The LPN was unsure when the catheter bag was last placed or changed, and the DON later could not confirm whether urinalysis or urine culture orders had been obtained in response to the abnormal urine. Another resident with obstructive and reflux uropathy had physician orders to change the urinary bag as needed when clinically appropriate. This resident, who was cognitively intact per a recent BIMS score, reported that the catheter bag was supposed to be changed once a week but that staff changed it only when they decided to. The January MAR included an order to change the urinary bag as needed when clinically appropriate, but again there was no documentation of any bag changes. When the wound care coordinator was asked about the appearance of the resident’s indwelling catheter, the coordinator described a white residue but did not explain what it indicated and then had to ask an LPN how often the order was to change the bag. A third resident had a care plan noting a nephrostomy bag with an intervention to observe for skin irritation and keep the skin clean, dry, and moisturized. This resident was observed in bed with the nephrostomy drainage bag resting on the abdomen, with only about one tablespoon of urine in the bag over a period of at least 15 minutes. A CNA stated she did not know what kind of urine bag it was but believed it should be hanging down on the side of the bed to allow proper drainage, and when she lowered the bag below the resident, approximately 200 ml of urine drained into the bag. An LPN initially was unsure what type of catheter it was and later confirmed it was a nephrostomy catheter connected directly to the kidney, acknowledging that the drainage bag should be placed below the resident to allow gravity drainage. The facility’s nephrostomy management policy required that the drainage bag be kept below the level of the kidney at all times, and the DON stated that backflow of urine could cause kidney infection.
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