F0656

D

Failure to Revise Care Plan and Perform IDT Root Cause Analysis for Recurrent Nephrostomy Tube Dislodgement

Whittier, California Survey Completed on 02-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to develop and revise a comprehensive, individualized care plan addressing recurrent nephrostomy tube dislodgement for a resident with bilateral nephrostomy tubes and complex medical conditions. The resident had diagnoses including anoxic brain damage, persistent vegetative state, artificial openings of the urinary tract (nephrostomy tubes), pyelonephritis, urinary calculi, and UTI. On admission and subsequent review, the care plan identified an alteration in urinary elimination and risk for UTI related to indwelling catheters (nephrostomy tubes), with an intervention to secure the left and right nephrostomy tubing with anchors each shift to minimize dislodgement. Despite this, the resident experienced multiple episodes of nephrostomy tube malfunction and dislodgement requiring hospital evaluation and tube exchanges.

On one occasion, facility records and GACH documentation showed the resident was admitted with percutaneous nephrostomy malfunction and UTI, underwent right and left nephrostomy tube exchange, received antibiotics, and was then readmitted to the facility. Later, a Change of Condition note documented that the treatment nurse notified an RN that the resident’s right nephrostomy tube was dislodged, with hematuria noted in the left nephrostomy bag, and the resident was again sent to the hospital, where records indicated admission for UTI and dislodged right nephrostomy tube and a right nephrostomy tube exchange with IV antibiotics. Subsequent Change of Condition documentation described a CNA reporting that the left nephrostomy tube appeared out of place, the urine collection bag was empty, and the gauze dressing used to keep the tube in place was off and saturated with urine. The RN observed the nephrostomy tube inside the stoma but 13.5 cm out with urine leaking from the stoma, and the physician was notified with a request to transfer the resident for replacement.

Further documentation showed another Change of Condition entry noting no urine output in the left nephrostomy bag and a new order from the physician to send the resident to the hospital for exchange. GACH records indicated the resident had multiple dislodged nephrostomies over the past few months, was paraplegic and bedbound, and had been seen at another hospital two to three days earlier for similar issues, with a subsequent left nephrostomy tube placement and antibiotics. Interviews with RN staff and the DON confirmed that, despite these recurring dislodgements, the care plan was not revised to include new or individualized interventions to prevent further nephrostomy tube dislodgement. RN 2 acknowledged that the care plan had not been updated with new interventions and stated it was important to keep the care plan updated. The DON stated that the IDT did not hold a meeting regarding the recurring nephrostomy tube dislodgements, that a root cause analysis was not done, and that it was never determined why the nephrostomy tubes continued to become dislodged, despite facility policy requiring ongoing assessment, IDT review, and care plan revision when desired outcomes are not met or after hospital readmissions.

The facility’s written policy on comprehensive person-centered care plans stated that the IDT, in conjunction with the resident and representative, develops and implements a comprehensive care plan derived from thorough assessment, reflecting recognized standards of practice, and addressing underlying causes of problem areas. The policy further required that assessments be ongoing and care plans revised as residents’ conditions change, with IDT review and updates when there is a significant change in condition, when desired outcomes are not met, and when a resident is readmitted from a hospital stay. In this case, despite multiple nephrostomy tube dislodgements, repeated hospital admissions for nephrostomy malfunction and UTI, and documentation from hospital providers noting multiple dislodgements over months, the facility did not conduct an IDT meeting, did not perform a root cause analysis, and did not revise the resident’s care plan with individualized, preventative interventions specific to nephrostomy tube dislodgement.