| 14 |
JEFFERSON DAVIS COMMUNITY HOSPITAL ECF |
255050 |
1320 WINFIELD STREET |
PRENTISS |
MS |
39474 |
2018-10-31 |
690 |
D |
0 |
1 |
63N611 |
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and staff interview, the facility failed to provide catheter care in a manner that would prevent infection and/or trauma for one (1) of two (2) resident observations of perineal care, Resident #30. Findings include: Review of Resident #30's face sheet revealed the facility admitted the resident on 9/27/18, with [DIAGNOSES REDACTED]. Review of the facility policy, Perineal Care, revised (MONTH) 2010, revealed if a resident had a catheter, 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 remained secure with a leg strap to reduce friction and movement at the insertion site. On 10/31/18 at 10:36 AM, observation of catheter care for Resident #30, revealed Certified Nursing Assistant (CNA) #1 provided catheter care, along with assistance of CNA #2. There was no leg strap or catheter securing device observed, 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 observed CNA #1 wiped toward the Urethra, or urinary Meatus, instead of away from it. On 10/31/18 at 11:27 AM, an interview with the Director of Nursing (DON) revealed that she expected Resident #30 to have a leg strap to secure the catheter. The DON stated that she also expected the CNA to clean the catheter tubing by wiping away from the Urethra, instead of toward the Urethra/Urinary Meatus. The DON stated that she expected the CNA to follow their policy for catheter care. On 10/31/18 at 12:00 PM, an interview with CNA #1 confirmed that she wiped incorrectly when she cleaned the Foley catheter for Resident #30. The CNA stated that she wasn't sure about the catheter securing device, because this was the first day she'd provided care for Resident #30. On 10/31/18 at 12:34 PM, an interview with CNA #2 revealed that she had observed the resident to have a leg strap the day before and that the resident should have a catheter strap on at all times to keep from pulling. The CNA reported that she knew to hold the catheter at the closest point to the urethra as possible. The CNA reported that CNA #1 should have wiped the tubing away from the Urethra while providing catheter care. Record review revealed that Resident #30 completed Intravenous (IV) [MEDICATION NAME], an antibiotic, on 10/16/18 for a UTI. The resident had a urinalysis with culture and sensitivity completed on 10/24/18, with no antibiotics prescribed for a UTI at this time. An interview with the DON on 10/29/18 at 3:49 PM, revealed they are waiting on the culture and sensitivity for the Physician to decide if Resident #30 needed treatment with antibiotics. 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, and should be cleaned from the insertion site to approximately four (4) inches outward. |
2020-09-01 |