State Findings:
Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter for 2 of 2 sampled residents (Resident #52 and #280) reviewed for indwelling urinary catheters.
Review of the facility’s policy titled, Catheter Care Procedure, dated 5/23/2018, revealed .Grasp catheter with two fingers to stabilize it .Provide perineal hygiene .Using a clean washcloth, clean catheter. Starting close to the urinary meatus, clean catheter .along its length for about 10 cm [centimeters], moving away from the body .reapply catheter securement device .
Observation in the resident’s room on 11/29/2021 at 10:10 AM and 4:00 PM, on 11/30/2021 at 8:23 AM and 4:27 PM, and on 12/1/2021 at 7:13 AM and 10:14 AM, revealed Resident #280 had an indwelling urinary catheter.
Review of the medical record revealed there was no Physician’s Order for Resident #280’s indwelling catheter.
During an interview on 12/1/2021 at 8:51 AM, the Director of Nursing and the Assistant Director of Nursing confirmed that there were no orders for the indwelling urinary catheter for Resident #280.
Observation in the resident’s room on 12/1/2021 at 10:18 AM, revealed Licensed Practical Nurse (LPN) #1 gathered supplies, donned her gloves, removed Resident #280’s brief, cleaned the right perineal area with a soapy wash cloth using a back and forth motion, and the cloth was noted to have a moderate amount of a brown substance. LPN #1 dried the resident with a towel in the same back and forth motion, removed her gloves, and washed her hands. LPN #1 then donned new gloves, and cleaned the left perineal area with a soapy wash cloth, using a back and forth motion, and the cloth was noted to have a moderate amount of a brown substance. LPN #1 dried the left perineal area with a towel using the same back and forth motion. LPN #1 then retrieved a package of wipes from a drawer, and wiped the catheter tubing from the port upward towards the resident. LPN #1 did not clean the catheter from the meatus down and contaminated the area with the brown substance. Resident #280 did not have a catheter securement device.
During an interview on 12/1/2021 at 1:56 PM, CNA #2 confirmed that she should wash her hands between glove changes and that the indwelling catheter should be secured.
During an interview on 12/1/2021 at 1:58 PM, LPN #1 confirmed that she should not have wiped back and forth during catheter care and that she should have cleaned the catheter from the meatus down. LPN #1 confirmed that the brown substance on the washcloth was feces. LPN #1 stated, .should have cleaned .got all the soap off .rinsed the soap off .pat dry .
Your Experience Matters
...and we want to hear it.
NHAA is here to assist families, residents, and the community by sounding the alarm on issues like those found above. This nursing home and many others across the country are cited for abuse and neglect.
If you have or had a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.
We have helped many already and we can help you and your loved one as well by filing a state complaint, hiring a specialized nursing home attorney or helping you find a more suitable location for your loved one.
You can make a difference, even if your loved one has already passed away.
Please give us a call at 1-800-645-5262 or fill out our form detailing your experience.
Personal Note from NHA-Advocates
NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety.
If you are struggling and upset, click here to understand your options, or contact us through our contact form or call our toll free hot line number: 1-800-645-5262.
