| 16 |
WASHINGTON CTR FOR AGING SVCS |
95014 |
2601 18TH STREET NE |
WASHINGTON |
DC |
20018 |
2019-07-30 |
726 |
E |
0 |
1 |
BMNI11 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews for two (2) of 56 sampled residents, the facility staff failed to provide competent nursing staff to care for one (1) resident with an indwelling Foley catheter who developed an penile injury; and failed to ensure nursing staff has specific competencies and skills to assess and care for one (1) resident who is [MEDICAL TREATMENT]-dependent and has a arteriovenous (AV) fistula graft site. Residents' #58 and #175. Findings included . 1. Facility staff failed to provide competent nursing staff to care for Resident #58 with an indwelling Foley catheter who developed an penile injury. Wound, Ostomy and Continence Nurses Society. (2016). Care and management of patients with urinary catheters: A clinical resource guide. MT. Laurel: N[NAME] Author Securement Devices: .Indwelling catheters should be secured to avoid traction on the catheter, which causes irritation and trauma to the urethra(e.g., urethritis, necrosis, erosion, stricture) .monitor the urethra daily for irritation, erosion, or urine leakage and assess the skin integrity under the securement device. Resident #58 was readmitted to facility on 12/21/18, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Comprehensive MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of the care plan for Foley Catheter due to [MEDICAL CONDITION] showed it was initiated on 1/23/2019. Goal: resident will have catheter care managed appropriately .not exhibiting signs of urinary tract infection or urethral trauma. Approach: .report signs of UTI .manipulate tubing as little as possible during care .provide catheter care .use catheter strap .use leg bag as needed . A review of Medical Record Revealed: A physician's orders [REDACTED]. Urology consult for UR 12/10/2018. Urology Consult-1/3/2019, Diagnosis; [MEDICAL CONDITION] with chronic indwelling Foley catheter and urethral erosion. A review of NP (Nurse Practitioner) progress note dated 5/31/2019, revealed, .10:36 PM Pt with UR, observed during day, unable to pee, Foley reinserted able to drain urine. Penis lacerated from previous Foley catheter with ulcer at glans Pt states pain burning at penis. Purulent drainage from penis . Foley inserted attached to right leg to avoid further laceration at left side avoid diaper when patient has Foley (to lacerate penis). 5/31/2019 - Interim Order, Please avoid diaper when pt. has a Foley (cause Laceration of penis) Foley inserted routine Foley care q shift. A review of NP Progress note dated 6/4/2019, .Pt with Foley catheter with ulcer of glans purulent drainage from penis . 6/5/2019- Interim Order, D/C order to avoid diaper when pt. has a Foley Use diaper to make it loose to prevent laceration. Urology Consult for possible Suprapubic catheter (6/20/2019) .Progress note [MEDICAL CONDITION] UTI (Urinary .Penile erosion .plan for SP (Suprapubic) tube placement under local . Urology consultation for [MEDICAL CONDITION] at (Hospital Name) at 1:30 PM with (Physician name) (07/03/19). Change Foley catheter q 6 weeks obtain medical records or other history to determine if there are reasonable alternative to indwelling Foley catheter . 7/5/2019- Urology Consult findings: S/P tube inserted under u/s (ultrasound) guidance New Diagnosis: [REDACTED].urethral erosion. 7/9/ 2019- Interim Order urology F/U (follow up) for Suprapubic Cath . Upon review of the nursing progress notes dated (MONTH) 1, 2019 through (MONTH) 30, 2019 showed no evidence the facility staff assessed the resident's genital-urinal status for complications (irritation and trauma to the penis or urethra) regarding indwelling Foley catheter prior to or after the penile laceration and erosion occurred and was documented by Nurse Practitioner resulting in the surgical insertion of the suprapubic catheter directly in to the Residents bladder for further care. Through record review, it was noted the resident was diagnosed with [REDACTED]. There was no evidence that facility staff conducted an initial and ongoing [MEDICAL CONDITION] assessment (size, discoloration of skin, odor, swelling, pain, drainage) and treatment plan to promote healing. On 5/31/19, the resident was noted with a laceration to his penis from previous Foley catheter with ulcer at glans, with pain burning and purulent drainage from penis. On 7/5/19, the resident had a suprapubic catheter inserted due to [MEDICAL CONDITION] and urethral erosion. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee # 3 who stated she did not know what erosion was and would look it up on the internet. 2. Facility staff failed to ensure nursing staff has specific competencies and skills to assess and care for a [MEDICAL TREATMENT]-dependent arteriovenous (AV) fistula graft site. Resident #175. Record review of the facility's undated policy titled, Care of Resident Receiving [MEDICAL TREATMENT] showed the nurse will check the thrill/bruit at the access site every shift. Caring for a Patient's Vascular Access for [MEDICAL TREATMENT]: Assess for patency at least every eight hours. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicates patency. Retrieved from: Nursing Management (2011). Resident #175 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE], showed resident Brief Interview for Mental Status (BIMS) is coded as 15 to indicate cognitively intact. Further review of the MDS showed Section O (Special Treatments, Procedures and Programs) resident is coded as receiving [MEDICAL TREATMENT]. Review of physician's orders [REDACTED]. Review of resident's care plan showed, [MEDICAL TREATMENT] Dependent: monitor [MEDICAL TREATMENT] arteriovenous fistula (AV) to left arm for bruit, thrill and bleeding. Review of the nursing assessment notes of the AV fistula site showed the following entries: 5/5/19: Thrill/Trust present. 5/14/19: No infection, thrill/trust present. 6/4/19: Thrill/Trust present at this time. 6/11/19: No infection noted, thrill/trust present. 7/16/19: Thrill/Trust was present. 7/17/19: Thrill/Trust present. On 7/25/19, at 1:00 PM an interview with Employee #15 in the presence of Employee #14. Employee #15 was asked how do you assess the resident's AV graft site. Employee #15 stated, I look for infection and bleeding. Employee #15 was asked what is a trust? Employee responded, That is when the blood is going back and forth. Employee #15 was asked do you use a stethoscope when assessing the AV fistula site. Employee #15 responded, No. There is no evidence the nurse assessing the AV fistula has the skill or competency to provide care in accordance with professional standards of practice; review of the medical showed there was no harm to the resident. At the time of the interview on 7/25/19, at 1:00 PM Employee#14 and Employee #15 acknowledged the finding. |
2020-09-01 |