Failure to Assess and Report Abnormal Urine and Catheter Findings
Penalty
Summary
The facility failed to assess, monitor, and provide timely medical interventions for a resident with an indwelling urinary catheter who exhibited signs consistent with possible urinary tract infection (UTI). The resident had multiple diagnoses, including neuromuscular dysfunction of the bladder and neurogenic bladder, and had an order for catheter care every shift. The care plan identified the resident as being at risk for infection related to the indwelling catheter and required staff to empty drainage bags regularly and monitor, record, and report signs and symptoms of UTI, such as cloudy urine and sediment. On two consecutive days, surveyors observed the resident’s catheter bag and tubing containing dark, cloudy yellow urine with large, thick white clumps of sediment. Despite these visible abnormalities, there were no corresponding progress note entries documenting the condition of the catheter, any assessment of the urine, or notification to the physician from the beginning of the month through the time of the survey. Staff interviews further demonstrated a lack of appropriate response to the resident’s catheter condition. A CNA reported being trained to look for blood, cloudiness, thickness, and darkness in catheter tubing or bags and to alert the nurse if such findings were present, but stated there were no observations or concerns regarding this resident’s catheter and no unusual occurrences reported from the previous shift. An agency LPN stated that signs of infection include sediment or blood in the tubing and cloudy urine, and that such findings should prompt a call to the physician for orders and urine testing, but reported being unaware of any concerns with the resident’s catheter and not receiving any report of sediment or cloudy urine. The DON stated that staff should observe for discoloration and other signs of potential infection and obtain physician orders when such signs are noted, and confirmed she had not been made aware of the resident’s catheter condition. Review of the facility’s urinary catheter care policy showed that staff are required to observe urine for unusual appearance, report findings to the physician and supervisor immediately, and document assessment data and urine characteristics, which was not done in this case.
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