Failure to Assess and Manage Indwelling Catheter Leading to Traumatic Urethral Bleeding
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and services for an indwelling urinary catheter for one resident, resulting in a prolonged period without assessment or intervention when the catheter was not draining. The resident, who was cognitively intact with a BIMS score of 15/15 and had significant urologic and renal diagnoses including paraplegia, cystitis with hematuria, hydronephrosis, acute kidney failure, and prior hematuria with stent placement, requested a new catheter when his urine was overflowing. An RN on duty declined to perform the catheter change and asked an LPN from another floor to insert the catheter. The LPN reported being very busy on his own floor but proceeded to insert a new indwelling catheter late at night. After the catheter insertion, the resident observed that no urine was draining and questioned whether the catheter was correctly placed. The LPN told him to give it time and drink water. Over the next several hours, the resident had no urine output and repeatedly sought help by using his call light and calling the facility’s main line multiple times, with delayed or no responses. At one point, the LPN admitted to the resident that he had fallen asleep. Eventually, the RN entered the room, deflated the catheter balloon, and blood immediately gushed into and over the catheter bag and onto the resident’s diaper and bedding. The resident documented the timing of his calls on his cell phone and recorded video showing significant blood in the catheter tubing, bag, and on his diaper. The resident ultimately called 911 himself and was transported to the hospital, where imaging showed the catheter balloon inflated in the bulbar urethra with free air and active extravasation, a distended bladder with a large amount of blood and air, and a significant drop in hemoglobin associated with hemodynamic instability. The facility’s records contained almost no nursing documentation of the catheter insertion, the absence of urine output, the resident’s repeated calls for help, the bleeding episode, or any assessments or interventions between approximately 11:30 PM and 3:00 AM. The DON, NP, Medical Director, and Administrator all confirmed that there were no progress notes from the involved nurses describing what occurred during that time, despite facility policy requiring documentation of catheter size, procedure, urine characteristics, and monitoring of intake and output, and despite a prior similar episode of catheter-related bleeding for this resident that had also resulted in a 911 call and hospital transfer.
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