§483.25(e) Incontinence.
§483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain.
§483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that-
(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary;
(ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and
(iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
§483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible.
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Observations:
Based on review of facility policy and clinical record review, it was determined that the facility failed to timely assess the need for an indwelling urinary catheter for one of seven residents reviewed for urinary tract infections (UTI) (Resident 61).
Findings include:
Review of facility policy, "Urinary Catheter Procedures," last revised December 30, 2022, revealed that "A resident who enters the [facility] with an indwelling urinary catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident ' s clinical condition demonstrates that catheterization is necessary ...Residents identified with an indwelling urinary catheter will be assessed by utilizing the Indwelling Catheter Observation Form in the Electronic Health Record (EHR). This observation form will be completed when the catheter is present on admission/readmission, when a catheter is inserted, and quarterly as long as the catheter remains in place ...Attempts will be made to remove the catheter as soon as possible when no indications exist for its continued use."
Review of Resident 61's clinical record revealed the resident was hospitalized from January 3, 2024 until January 5, 2024, for a fractured left hip with surgical repair. Review of Resident 61's physician's orders at the time of hospitalization revealed the resident did not have a foley catheter at the time. Review of Resident 61's hospital discharge summary from January 5, 2024 revealed the instructions: "Continue Foley catheter for urinary retention, do void trial at skilled facility as ambulation improves."
Further review of Resident 61's clinical record failed to reveal evidence that an Indwelling Catheter Observation Form was completed upon the resident's January 5, 2024 readmission.
Further review of Resident 61's clinical record failed to reveal evidence that a void trial was attempted.
Review of Resident 61's January 2024 Treatment Administration Record revealed the resident was documented as receiving catheter care every shift.
Review of Resident 61's progress note revealed a nurse's note on January 19, 2024, at 12:06 a.m. which stated: "Resident's urine observed cloudy with sediment. [supervisor] notified, VSS [vital signs stable], fluids encouraged as tolerated. Nursing will continue to monitor." Further review of Resident 61 ' s January 19, 2024 progress notes revealed a nurse's note at 2:32 p.m. which stated: "Resident's foley output 120cc, cloudy and with sediment. No foul odor. VSS. Fluids encouraged. Nursing will monitor." Further review of Resident 61's January 19, 2024 progress notes revealed a nurse's note at 5:11 p.m. which stated: "Resident reported to have cloudy urine with some confusion. UA/CS [(urine analysis/culture & sensitivity] order obtained."
Further review of Resident 61's clinical record revealed the resident was sent to the hospital for hyponatremia (low sodium) on January 22, 2024, until January 30, 2024 and was subsequently found to have a UTI at the hospital and treated with antibiotics.
Review of Resident 61's progress notes revealed a note from the CRNP (certified registered nurse practitioner) on February 16, 2024, which stated: "Foley catheter not chronic despite documentation of it being chronic by ED ([Emergency Department])... Resident returned from ED visit on 1/5/24 with foley with instructions to keep in place and do void trial at facility. Resident was sent out to ED with UTI due to catheter on 1/22/24. Plan of care: remove foley catheter now."
Interview with the Assistant Director of Nursing on June 14, 2024, at 10:40 a.m. confirmed the facility failed to assess Resident 61 for the need for the foley catheter upon readmission from the hospital.
28 Pa. Code 211.12 (d)(3)(5) Nursing services
28 Pa. Code 211.10 (a)(c)(d) Resident care policies
| | Plan of Correction - To be completed: 08/09/2024
The indwelling catheter for Resident 61 was discontinued without difficulty per order of the Certified Registered Nurse Practitioner on February 16, 2024.
All residents with an indwelling catheter on admission or readmission or have a new provider order for an indwelling catheter inserted since August 1, 2023, will be reviewed for completion of the "Indwelling Catheter Observation" and voiding trial if clinically indicated.
All Registered Nurses, Registered Nurse Supervisors, and Infection Prevention Registered Nurses will be reeducated by the Registered Nurse Instructors on the Urinary Catheter Procedures including completion of the Indwelling Catheter Observation and voiding trial if indicated for the resident.
The Nurse Manager (Assistant Director of Nursing) or designee will complete audits of residents admitted with a catheter, readmitted with a new catheter, or with a newly placed indwelling catheter to review for the Indwelling Catheter Observation and voiding trial when ordered. Audits will be conducted weekly for 8 weeks. The results of the audits will be reviewed at the Quality Assurance Process Improvement meeting.
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