Failure to Monitor and Assist With Indiana Pouch Catheterization Leading to Acute Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure necessary assessment, monitoring, and assistance with catheterization for a resident with an Indiana pouch, resulting in hospitalization for sepsis. The resident had diagnoses including paraplegia, an Indiana pouch (continent urinary reservoir), pressure-related wounds, and chronic pain syndrome treated with routine pain medications. Her care plan indicated she required some assistance with ADLs due to paraplegia, muscle wasting, and intermittent catheterization, and specified that straight catheterization of the Indiana pouch was to occur every 4 hours. Although the resident was considered competent to self-catheterize, the care plan and physician orders directed staff to offer assistance with catheterization every 4 hours, especially at night, document urine output, and observe for signs and symptoms of UTI. On the date in question, the Treatment Administration Record showed that scheduled catheterizations at 8:00 a.m. and 12:00 p.m. were not completed and no urine output was recorded. The nurse’s initials and notation to refer to progress notes were present, but there were no corresponding progress notes during that time frame explaining why catheterization was not done or why there was no output. Later that afternoon, a progress note documented that the resident had been lethargic during the day, and when the nurse went to change dressings, the resident’s abdomen was observed to be distended and painful. The nurse attempted to assist the resident with catheterizing the pouch but was unsuccessful, and the on-call NP was notified with orders to send the resident to the ER for mental status change, distended abdomen, inability to catheterize, and wound changes. Hospital records documented that the resident reported abdominal pain beginning around lunchtime and decreased appetite over the preceding days. She stated she self-catheterized her Indiana pouch but had not obtained any urine that day and had been unable to remove urine since the previous night. Examination revealed a distended abdomen, and after gentle dilation of the urostomy, a catheter was placed and 2 liters of urine with large amounts of mucus and blood were drained from the pouch. Laboratory results showed a markedly elevated WBC, positive urine for blood, WBCs, and bacteria, low sodium, and elevated creatinine, and she was admitted for leukocytosis, acute kidney injury, urinary retention, and hyponatremia. The DON later indicated she was not aware that catheterizations had not been performed or documented earlier that day, and acknowledged there should have been documentation in the TAR or progress notes explaining why catheterization was not done. The facility’s Indiana pouch management policy required assessment of the resident’s ability to perform self-care with any change in condition and nursing monitoring for changes in continence and signs of infection or complications.
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