| 13 |
JEFFERSON DAVIS COMMUNITY HOSPITAL ECF |
255050 |
1320 WINFIELD STREET |
PRENTISS |
MS |
39474 |
2018-10-31 |
656 |
D |
0 |
1 |
63N611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interview, the facility failed to develop a comprehensive care plan to include interventions of a catheter securing device to prevent tension and trauma; and failed to implement the care plan of providing catheter care in a manner to help prevent infection for one (1) of four (4) care plans reviewed, Resident #30. Findings include: Review of the facility policy, Care Plans, Comprehensive Person-Centered, revised (MONTH) (YEAR), revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed that the facility policy, if a resident had a catheter, was to gently wash the juncture of the tubing from the Urethra down the catheter about three (3) inches. The facility policy also noted that the catheter tubing should be held to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. Review of the facility policy, Catheter Care, Urinary, revised (MONTH) 2014, revealed the urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. The policy also included documentation to ensure that the catheter remains secure with a leg strap to reduce friction aandmovement at the insertion site. Record review revealed Resident #30's care plan, with an on-set date of 10/8/18, revealed a potential for complications related to an indwelling urinary catheter. Interventions included to keep the catheter and drainage bag lower than the bladder at all times and to provide catheter care with soap and water every shift. The care plan did not address the use of a securing device (leg strap). Review of Resident #30's face sheet revealed that she was admitted on [DATE], with a [DIAGNOSES REDACTED]. Observation on 10/31/18 at 10:36 AM, revealed Certified Nursing Assistant (CNA) #1 provided catheter care for Resident #30, along with assistance of CNA #2. Both CNA's were observed to wash hands prior to providing catheter care. Observation revealed there was no leg band to secure the catheter tubing to prevent the catheter from pulling at the Urethra. CNA #2 held the catheter bag above the Resident's bladder and was holding the catheter at the junction of where it meets the bag tubing, instead of securing it at the Urethra. Then, CNA #1 wiped toward the Urethra, instead of away from it. On 10/31/18 at 12:00 PM, interview with CNA#1 revealed that she knew that she wiped incorrectly when she cleaned Resident #30's Foley catheter. The CNA reported she was not sure about a catheter strap, today was her first day to take care of the resident. On 10/31/18 at 12:34 PM, interview with CNA #2 revealed Resident #30 had a leg strap on the day prior. The CNA reported that the resident should have a catheter strap on at all times to help prevent trauma from pulling. The CNA reported that she knew to hold the catheter at the closest point to the Urethra as possible and that CNA #1 should have wiped away from the Urethra, instead of toward it, while providing catheter care. On 10/31/18 at 11:27 AM, interview with the Director of Nursing (DON) revealed that she expected the resident to have a leg strap to secure the catheter. The DON stated that she expected the CNA to wipe the resident from front to back when providing perineal/catheter care and for staff to clean the catheter by wiping away from the Urethra. The DON reported that she expected the CNA to follow the care plan, which included providing care per the policy. Review of the staff education training, dated (MONTH) (YEAR), on incontinent catheter and peri- care, revealed that staff was trained on assuring that the catheter must be below the bladder at all times to prevent urine from flowing back into the bladder. The training also revealed that the catheter should have a secure leg band on and the catheter should be cleaned from the insertion site to approximately four (4) inches outward. |
2020-09-01 |