Failure to Monitor Foley Catheter Output and Respond to Catheter-Related Symptoms
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate monitoring and care of an indwelling urinary catheter for one resident. The resident had diagnoses including neuromuscular dysfunction of the bladder, benign prostatic hypertrophy, cerebrovascular accident, and anxiety disorder, and had a chronic Foley catheter with substantial assistance needed for toileting and hygiene. A physician’s order had directed staff to monitor urinary catheter output every shift, but this order was discontinued in mid-December, and nursing staff did not continue to obtain or document urinary outputs each shift. An LPN later indicated it was unclear why the order had been discontinued and why staff had not monitored urinary output as expected. The facility’s own catheter policy required ongoing care, monitoring of the resident’s response to catheter use, and monitoring for changes in condition related to potential catheter-associated UTIs. In the days following discontinuation of the urinary output order, nursing notes documented that the resident complained of penile pain, with pus coming from the head of the penis, and requested removal of the Foley catheter. Staff documented severe pain throughout the evening, treated with Tylenol and lubricant applied to the penis. The next day, the Foley catheter was changed and a urine sample was obtained via clean catch through the new catheter. The following day, the resident was found with an elevated temperature, shaking, gray discoloration of hands and lips, pain with the Foley catheter, and white drainage from the penis around the catheter, leading to a verbal order to send him to the hospital. In the emergency room, the Foley catheter was found displaced with the balloon in the penile shaft, and the resident was diagnosed with a UTI and early sepsis with borderline shock related to a UTI due to the displaced Foley catheter. The resident and his sister reported that the catheter had been dislodged or incorrectly placed, with bloody and purulent urine in the tubing and another catheter being inserted, and that he had recently been hospitalized for sepsis.
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