The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

BRATTLEBORO RETREAT ANNA MARSH LANE PO BOX 803 BRATTLEBORO, VT 05301 Oct. 4, 2016
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, nursing staff failed to incorporate within the interdisciplinary care plan the management and interventions for 1 applicable patient with a Foley indwelling catheter. (Patient #1) Findings include:

Patient #1, was admitted on [DATE]. The patient's medical history includes having a neurogenic bladder (malfunctioning urinary bladder due to neurological dysfunction) from a traumatic injury resulting in urinary retention and the need to utilize a Foley catheter (indwelling urethral catheter for the treatment of bladder dysfunction). Although the nursing care plan identified Patient #1 had a Foley catheter, there was a failure to assess the patient's needs for specific supplies and nursing interventions to assure the appropriate and safe management of the Foley catheter was maintained during Patient #1's hospitalization .
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
Based on interview and record review there was a failure to ensure nursing personnel had received the appropriate direction and guidance and had demonstrated experience and competency when assigned to provide nursing care in accordance with hospital policy for 1 applicable patient's specific care needs.(Patient #1). Findings include:

After 3 weeks of orientation, a newly hired graduate nurse (Nurse #1) became a member of the evening staff on a patient unit. Patient assignments were initiated along with monitoring of performance and training by Professional Development of this newly hired employee. On the evening of 7/24/16 Nurse #1 was assigned to Patient #1, an individual whose medical history includes having a neurogenic bladder (malfunctioning urinary bladder due to neurological dysfunction) from a traumatic injury resulting in urinary retention and the need to utilize a Foley catheter (indwelling urethral catheter for the treatment of bladder dysfunction). During the evening of 7/24/16 Patient #1 informs Nurse #1 "...the Foley is not draining". When discussed with the evening charge nurse, Nurse #1 was directed to have the patient flush/irrigate his/her Foley to determine if the catheter was clotted and/or plugged. The evening charge nurse directs Nurse #1 to draw up sterile saline into 3 10 ML syringes. Nurse #1 was then directed to have Patient #1 go into a unit bathroom and be provided the saline filled syringes for the purpose of having the patient flush/irrigate the Foley catheter. Nurse #1 was accompanied by a second nurse and both remained in the unit bathroom with Patient #1 but did not visualize the flushing procedure. At completion of the unobserved procedure, Patient #1 reports the flushing may of helped. However, over the course of the following 4 hours, the patient's urinary collection bag (connected to the Foley catheter) reportedly had approximately only 50 cc of urine. At approximately 10:27 PM Patient #1 reports to the evening charge nurse the Foley "...isn't draining". Additional flushing was suggested by the evening charge nurse. Patient #1 refused to flush/irrigate the Foley again, proceeded to return to the bathroom and removed the Foley catheter and requested to be transferred to the local hospital Emergency Department for evaluation and reinsertion of a new Foley catheter. A clinic consult was made and the patient was examined by a Nurse Practitioner (NP) at 01:00 on 7/25/16. With the assistance of the NP, Patient #1 reinserted a Foley catheter obtaining immediate drainage of 400 cc of urine.

Per interview on 10/4/16 at 8:46 AM the evening charge nurse confirmed s/he failed to obtain a physician order for the flushing/irrigation of Patient #1's Foley catheter nor was there approval for the patient to flush his/her Foley catheter and confirmed s/he had directed Nurse #1 to have the patient do the flushing as opposed to Nurse #1 performing the procedure. This oversight and direction by the evening charge nurse with Nurse #1 and the management of the patient's medical condition failed to follow hospital policy and did not demonstrate standards of nursing practice. Nurse #1 stated the reason for having the patient do the flushing/irrigation of his/her Foley catheter instead of the nurse was because the evening charge nurse stated Patient #1 was seeking "..secondary gains" and did not want the procedure to be perceived as "..inappropriate contact".

Per interview on 10/4/16 at 11:11 AM the Chief Nursing Officer (CNO) and VP of Patient Care Services confirmed nursing staff failed to follow hospital policy Nursing Care Procedures last reviewed 01/2015 which states nursing leadership have reviewed and "...approved the resources contained in Lippincott's Manual of Nursing, Tenth Edition as the approved Standards of Nursing Care for patients with medical issues requiring nursing intervention. Staff should access the pertinent area of information in creating a plan of care and intervening with typical medical issues requiring nursing intervention." Nursing care procedures did include: Urinary Catheters and Catherization page 777-783.

Per review of Lippincott's Manual of Nursing Tenth Edition Procedure Guidelines 21-3 Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage (page 782) states to irrigate the catheter "This is not done unless ordered to relieve obstruction.....". It further directs the nurse to use aseptic technique, place a sterile drainage basin under the catheter to maintain sterility, "Connect a large-volume syringe to the catheter using prescribed amounts of of sterile irrigant....instilling 60 ml of irrigating solution at a time.....remove syringe and place catheter over drainage basin, allowing returning fluid to drain into basin......disinfect the distal end of the catheter and end of drainage tubing; reconnect catheter and tubing."

The evening charge nurse failed to appropriately supervise and direct Nurse #1 to assure the care needs for Patient #1 were being provided in accordance with hospital policy and standards of nursing practice. Both nurses failed to refer to the Lippincott" Manual as directed per policy. They subjected the patient to potential cross contamination when the patient was directed into a unit bathroom, told to flush/irrigate with the wrong size syringes, and disregarded the patient's concerns and awareness the Foley catheter, for whatever reason, was not functioning as expected. Patient #1 subsequently removed the Foley catheter, was seen and examined by a Clinic NP who then oversaw the patient recatherize himself/herself resulting in immediate drainage of 400 ML of urine, demonstrating urinary retention which required a functioning Foley catheter.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview and record review, the hospital Infection Control program failed to assure staff consistently maintained infection control standards of practice in all areas of the hospital. Findings include:

Patient #1, was admitted on [DATE]. The patient's medical history includes having a neurogenic bladder (malfunctionary urinary bladder due to neurological dysfunction) from a traumatic injury resulting in urinary retention and the need to utilize a Foley catheter (indwelling urethral catheter for the treatment of bladder dysfunction). Per nursing progress note on the evening of 7/24/16, Nurse #1 documents the patient stated: "....the Foley is not draining". The evening charge nurse directs Nurse #1 to draw up sterile saline into 3 10 cc syringes. Nurse #1 was then directed to have Patient #1 go into a unit bathroom and be provided the saline filled syringes for the purpose of having the patient flush/irrigate the Foley catheter. Nurse #1 was accompanied by a second nurse and both remained in the unit bathroom with Patient #1 but did not visualize the flushing procedure. At completion of the flushing, Patient #1 reports the flushing may of helped. However, over the course of the following 4 hours, the urinary collection bag (connected to the Foley catheter) reportedly had approximately only 50 cc of urine. At approximately 10:27 PM Patient #1 reports to the evening charge nurse the Foley "...isn't draining". Additional flushing was suggested. Patient #1 refused and proceeded to return to the bathroom and removed the Foley catheter and requested to be transferred to the local hospital Emergency Department for evaluation and reinsertion of a new Foley catheter. A clinic consult was made and the patient was examined by a Nurse Practitioner (NP) at 01:00 on 7/25/16. With the assistance of the NP, and utilizing aseptic technique, Patient #1 reinserted a Foley catheter obtaining immediate drainage of 400 ml of urine.

Per interview on 10/4/16 at 11:11 AM the Chief Nursing Officer (CNO) and VP of Patient Care Services confirmed nursing staff failed to follow hospital policy Nursing Care Procedures last reviewed 01/2015 which states nursing leadership have reviewed and "...approved the resources contained in Lippincott's Manual of Nursing, Tenth Edition as the approved Standards of Nursing Care for patients with medical issues requiring nursing intervention. Staff should access the pertinent area of information in creating a plan of care and intervening with typical medical issues requiring nursing intervention." Nursing care procedures did include: "Urinary Catheters and Catherization".

Per review of Lippincott's Manual of Nursing Tenth Edition Procedure Guidelines 21-3 Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage (page 782) states to irrigate the catheter "This is not done unless ordered to relieve obstruction.....". It further directs the nurse to use aseptic technique, place a sterile drainage basin under the catheter to maintain sterility, "Connect a large-volume syringe to the catheter using prescribed amounts of of sterile irrigant....instilling 60 ml of irrigating solution at a time.....remove syringe and place catheter over drainage basin, allowing returning fluid to drain into basin......disinfect the distal end of the catheter and end of drainage tubing; reconnect catheter and tubing."

Nursing staff failed to follow hospital policy, failed to maintain standards of infection control practice regarding the irrigation/flushing of Patient#1's Foley catheter to include improper irrigation equipment, lack of aseptic technique, exposure of Patient #1 to possible cross contamination of Foley catheter when directed to self irrigate/flush catheter in a bathroom over a toilet used by multiple unit patients. Per HICPAC (Healthcare Infection Control Practices Advisory Committee) Guideline for Preventing Catheter-Associated Urinary Tract Infections (CAUTI), 11/13/2008 " V. Administrative infrastructure B. Education and Training: Ensure that healthcare personnel and others who take care of catheters are given periodic in-service training" and " C. Supplies: Ensure that supplies necessary for aseptic technique are available." Specific staff training pertenent to the managment of Patient #1's Foley catheter was not evident nor were correct supplies available or utilized for the flush/irrigation of the catheter.

It was further confirmed by the hospital's Infection Control Preventionist on 10/4/16 at 1:40 PM nursing staff failed to maintain aseptic technique, and breached standards of infection control practice on 7/24/16.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, nursing staff failed to provide an ongoing appropriate assessment and perform nursing care in accordance with accepted standards of practice and hospital policy for 1 applicable patient. (Patient #1) Findings include:

Patient #1, was admitted on [DATE]. The patient's medical history includes having a neurogenic bladder (malfunctioning urinary bladder due to neurological dysfunction) from a traumatic injury resulting in urinary retention and the need to utilize a Foley catheter (indwelling urethral catheter for the treatment of bladder dysfunction). Per nursing progress note on the evening of 7/24/16, Nurse #1 documents the patient stated: "....the Foley is not draining". The evening charge nurse directs Nurse #1 to draw up sterile saline into 3 10 ml syringes. Nurse #1 was then directed to have Patient #1 go into a unit bathroom and be provided the saline filled syringes for the purpose of having the patient flush/irrigate the Foley catheter. Nurse #1 was accompanied by a second nurse and both remained in the unit bathroom with Patient #1 but did not visualize the flushing procedure. At completion of the flushing, Patient #1 reports the flushing may of helped. However, over the course of the following 4 hours, the urinary collection bag (connected to the Foley catheter) reportedly had approximately only 50 ml of urine. At approximately 10:27 PM Patient #1 reports to the evening charge nurse the Foley "...isn't draining". Additional flushing was suggested. Patient #1 proceeded to return to the bathroom and removed the Foley catheter and requested to be transferred to the local hospital Emergency Department for evaluation and reinsertion of a new Foley catheter. A clinic consult was made and the patient was examined by a Nurse Practitioner (NP) at 01:00 on 7/25/16. With the assistance of the NP, Patient #1 reinserted a Foley catheter obtaining immediate drainage of 400 ml of urine.

Per interview on 10/4/16 at 8:46 AM the evening charge nurse confirmed s/he failed to obtain a physician order for the flushing of Patient #1's Foley catheter nor was there approval for the patient to flush his/her Foley catheter and confirmed s/he had directed Nurse #1 to have the patient do the flushing as opposed to Nurse #1 performing the procedure. Per interview on 10/4/16 at 11:11 AM the Chief Nursing Officer (CNO) and VP of Patient Care Services confirmed nursing staff failed to follow hospital policy Nursing Care Procedures last reviewed 01/2015 which states nursing leadership have reviewed and "...approved the resources contained in Lippincott's Manual of Nursing, Tenth Edition as the approved Standards of Nursing Care for patients with medical issues requiring nursing intervention. Staff should access the pertinent area of information in creating a plan of care and intervening with typical medical issues requiring nursing intervention." Nursing care procedures did include: Urinary Catheters and Catherization page 777-783.

Per review of Lippincott's Manual of Nursing Tenth Edition Procedure Guidelines 21-3 Management of the Patient with an Indwelling (Self-Retaining) Catheter and Closed Drainage (page 782) states to irrigate the catheter "This is not done unless ordered to relieve obstruction.....". It further directs the nurse to use aseptic technique, place a sterile drainage basin under the catheter to maintain sterility, "Connect a large-volume syringe to the catheter using prescribed amounts of of sterile irrigant....instilling 60 ml of irrigating solution at a time.....remove syringe and place catheter over drainage basin, allowing returning fluid to drain into basin......disinfect the distal end of the catheter and end of drainage tubing; reconnect catheter and tubing."

Nursing staff failed to follow hospital policy, failed to maintain standards of nursing practice regarding the flushing of Patient#1's Foley catheter to include improper irrigation equipment, lack of aseptic technique, exposure of Patient #1 to possible contamination of Foley catheter when directed to self irrigate/flush catheter in a bathroom used by multiple unit patients and failed to properly assess the patient when complaints and concerns were voiced by the patient regarding his/her neurogenic bladder and urinary retention issues.