Failure to Recognize and Respond to Catheter Complication and Resident’s Urgent Calls
Penalty
Summary
The deficiency involves the facility’s failure to ensure nursing staff had and demonstrated the competencies needed to recognize, assess, and respond to an acute change in condition and urgent calls for help for a resident with an indwelling urinary catheter. The resident, who is cognitively intact with a BIMS score of 15/15 and has diagnoses including paraplegia, urinary device management, cystitis with hematuria, hydronephrosis, acute kidney failure, and kidney/ureter calculi, requested a new catheter when his urine was overflowing. An RN on the unit 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 the catheter late at night. After insertion, no urine drained, and when the resident questioned the placement, the LPN told him to give it time and drink water. Over the next several hours, the resident experienced continued lack of urine output and repeatedly attempted to obtain assistance. He activated his call light without response, then called the facility’s main line multiple times, with calls documented on his cell phone. On one call, the LPN answered and asked for 25 minutes before coming; on another, the LPN later admitted to the resident that he had fallen asleep. The resident reported hearing the LPN and RN in the hallway discussing who would address the problem. Eventually, the RN entered the room, deflated the catheter balloon, and blood immediately gushed into and over the catheter bag, onto the sheets, diaper, and the resident. The RN appeared startled and called the LPN back into the room. The resident then made additional calls to the building line as bleeding continued, and when the nurses returned, he told them not to touch him and to call an ambulance. The resident ultimately called 911 himself, and paramedics arrived and transported him to the hospital. Hospital records documented a traumatic indwelling catheter insertion with CT imaging showing the catheter balloon inflated in the bulbar urethra with free air and contrast extravasation consistent with active bleeding, a distended bladder with a large amount of blood and air, and a hemoglobin drop from 13.2 to 6.5 with hemodynamic instability requiring ICU-level care. The facility’s Administrator later stated she was not aware of the severity of the injury until reviewing the hospital diagnosis of traumatic urethral bleeding. The DON reported that the RN had said she was not comfortable with male catheters and had asked the LPN for help, and that she was unsure what caused the bleeding. The NP believed the catheter had been inserted in the wrong place and not fully advanced. There were no nursing progress notes by either nurse documenting the assessment, catheter insertion, lack of urine output, resident’s repeated calls for help, or the bleeding episode between late night and early morning, despite facility policy requiring documentation of catheter size, procedure, urine characteristics, and resident response, and guidance to check for low output and notify a physician or NP when indicated. The only notes around the event were brief entries indicating the resident was sent to the hospital and later admitted for traumatic urethral bleeding, and the medical record contained no documentation that the resident had ever removed his own catheter.
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