Failure to Monitor Anticoagulated Resident After Traumatic Foley Catheter Dislodgement
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards of practice for a newly admitted resident who was on both an anticoagulant (warfarin) and an antiplatelet (clopidogrel). The resident had diagnoses including Alzheimer’s disease, delirium, and stage 3B chronic kidney disease, and the MDS documented severe communication impairment and behavioral symptoms. Despite physician orders for warfarin and clopidogrel, there was no baseline care plan created for monitoring the resident’s use of these blood-thinning medications, and the DON later acknowledged there would be an expectation for monitoring for bleeding and bruising and PT/INR labs for warfarin. On the night in question, the resident got out of bed, pulled out the indwelling Foley catheter, left the room, and fell outside the room door. A Fall Protocol Checklist recorded the fall time as 23:30, while an RN progress note documented the event at 00:30, creating a discrepancy in the recorded time of the fall. The RN note described the resident as aggressive toward staff, with abrasions to the left forearm and left lower back, and bleeding from the penis likely due to traumatic catheter dislodgement. The RN reinserted the catheter, noting initial drainage of blood clots that then thinned out, and documented the resident’s complaint of bladder pain. Following this event, the resident continued to have hematuria. A medication administration note the next morning documented that the resident was in pain from the dislodged Foley, had hematuria in the Foley line and bag, that the Foley appeared partially out, and that there was dried blood around the penis. A subsequent progress note documented dried blood around the penis, groin, and right leg, blood throughout the Foley tubing and into the bag, and that the Foley securement device suggested the catheter had been pulled and dislodged. The unit manager reported that hematuria had been noted the previous day and that the resident was being monitored on a 24-hour board, but no documentation of such monitoring or ongoing assessments was provided. Surveyors identified a lack of documented assessments and monitoring of the resident’s hematuria and condition during approximately eight hours between the catheter trauma and the resident’s transfer to the hospital for hematuria.
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