HospitalInspections.org

Based on policy manual review, medical record review and staff and family interviews, the hospital nursing staff failed to ensure urinary catheter care was performed per hospital policy for 3 of 6 patients with an indwelling urinary catheter (#9, 1 and 10).

Findings include:

Policy manual review on 02/04/2016 revealed "Urinary Catheter Insertion and Management" last reviewed 06/08/2015 which stated "Routine hygiene(e.g., cleansing of the meatal [opening into urinary meatus] surface during daily bathing) is appropriate."

1. Open medical record review for Patient #9, conducted on 02/03/2016, revealed a hospital admission on 01/26/2016. Review of nursing notes for 01/26/2016 through 02/03/2016 revealed an indwelling urinary catheter was inserted on 01/26/2016 without difficulty. Continued review revealed no documentation of urinary catheter care for 7 of 9 days the patient had an indwelling urinary catheter.

Interview with Patient #9's family member on 02/03/2016 at 1155 revealed Patient #9 had an indwelling urinary catheter inserted on the day of hospital admission on 01/26/2016. The interview revealed Patient #9 was at risk for skin breakdown and could not use the bathroom without a catheter. The interview revealed a nursing assistant assisted the patient and family with the patient's personal hygiene daily.

Interview on 02/04/2016 at 1315 with the Director of Accreditation and Regulatory Compliance revealed the expectation is for indwelling urinary catheter care be conducted with soap and water on each shift. The interview revealed the policy for indwelling urinary catheter care was not consistent with the expectation of every shift catheter care.

2. Closed record review for Patient #1, conducted on 02/02/2016, revealed a hospital admission, via the Emergency Department (ED), on 12/27/2015. Review of ED nursing notes revealed a 16 French (size of catheter) indwelling urinary catheter was inserted without difficulty at 1349. Review of nursing notes for 12/27/2015 through 12/29/2015 at 1935, when the catheter was removed, revealed no documentation of urinary catheter care for 3 of 3 days the patient had an indwelling urinary catheter.

Interview on 02/04/2016 at 1315 with the Director of Accreditation and Regulatory Compliance revealed the expectation is for indwelling urinary catheter care be conducted with soap and water on each shift. The interview revealed the policy for indwelling urinary catheter care was not consistent with the expectation of every shift catheter care.

3. Open medical record review for Patient #10, conducted on 02/03/2016, revealed a hospital admission on 01/31/2016. Review of nursing notes for 01/31/26 through 02/03/2016 revealed an indwelling urinary catheter was inserted on 01/31/2016 without difficulty. Continued review revealed no documentation of urinary catheter care for 2 of 4 days the patient had an indwelling urinary catheter.

Interview on 02/04/2016 at 1315 with the Director of Accreditation and Regulatory Compliance revealed the expectation is for indwelling urinary catheter care be conducted with soap and water on each shift. The interview revealed the policy for indwelling urinary catheter care was not consistent with the expectation of every shift catheter care.