Failure to Address Catheter-Related Pain and Maintain Proper Catheter Positioning
Penalty
Summary
The deficiency involves the facility’s failure to appropriately assess and respond to a resident’s significant increase in groin pain following a urinary catheter change, and failure to maintain proper positioning and securement of another resident’s indwelling urinary catheter and drainage bag. One resident, cognitively intact and with a history of neurogenic bladder requiring an indwelling catheter, reported severe burning and razor blade-like pain in the groin and scrotal area beginning after a catheter change. Over several days, the resident repeatedly stated that the pain was intense, interfered with eating, and that he felt no one was paying attention to it, although he acknowledged receiving pain medication that only partially helped. Nursing staff, including an RN, were aware of the resident’s ongoing groin pain and were administering tramadol, and the DON and ADON knew he was in pain and had an upcoming urology appointment. However, they were unsure whether the physician had been notified, and it was later confirmed that no one had contacted the physician about the new or increased pain following the catheter change. The resident’s EMR contained no documentation of his pain complaints despite staff awareness and administration of pain medication. The resident’s care plan for indwelling catheter use included monitoring for signs and symptoms of UTI and notifying the MD of abnormal findings, and the facility’s pain management policy defined pain as what the resident says it is and allowed for notifying the health care provider of new or changed pain, but these provisions were not followed in relation to his reported catheter-associated pain. A second resident with an indwelling urinary catheter was observed lying on their side with the catheter exiting through the back of an incontinent brief, unsecured, and with the drainage tubing suspended off the bed so that the weight of the tubing held the catheter taut. When staff repositioned the resident up in bed, the catheter stretched, and the tubing remained under the resident’s leg. A CNA then lifted the urinary collection bag above the level of the bladder, causing urine in the collection tubing to flow back toward the catheter. The CNA acknowledged the resident should not be lying on the catheter tubing and that the securing device had come loose, noting that the securing device is applied by a nurse. The facility’s indwelling catheter care policy required securing and anchoring the catheter with a leg strap or other device, which was not done in this instance.
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