IDPH has cited and fined Burbank Rehabilitation Center when the facility failed to properly assess, change, or flush a resident’s urinary catheter after no urine output was recorded for an entire eight-hour shift. The negligence resulted in the resident retaining 1,450 mL of urine in the bladder (maximum capacity is 900-1500 mL) and subsequently requiring hospitalization for a urinary tract infection and acute kidney injury.
The resident in question, suffering from quadriplegia and neuromuscular dysfunction of the bladder, began showing signs of distress when nursing notes indicated that the resident “refused breakfast and lunch” and “reported not feeling well.” Despite these warning signs, no action was taken regarding the resident’s urinary catheter, which had been in place for approximately one month.
The situation escalated when the resident’s urinary catheter was observed to be leaking and the resident was exhibiting confusion. However, the physician was not notified of these developments until later in the day when the resident’s vital signs had become critical. The physician ordered the catheter to be changed, but this was not done before the resident was sent to the hospital via emergency services.
Upon arrival at the hospital, the resident was diagnosed with “severe sepsis, acute kidney injury, and low sodium levels.” Hospital records noted that the resident’s “bladder was palpable at the umbilicus” and that the urinary catheter was “completely dry and had not likely been draining for some time.” When the catheter was removed and replaced, “urine began pouring from the patient,” with a total output of 1450 mL recorded in the emergency department.
The facility’s Medication Administration Record (MAR) showed no documentation of the catheter being changed or flushed, despite an order to “change the urinary catheter for blockage and/or leaking” and to “monitor output every shift.” Notably the night shift had documented a urine output of 0 mL, but no action was taken in response to this lack of output.
Multiple staff members, including nurses and a nurse practitioner, confirmed in interviews that a lack of urine output should have prompted immediate action. A Nurse Practitioner stated, “There should not be zero documented for urinary output during a shift,” and explained that retaining urine can cause altered mental status, kidney failure, and sepsis.
The Director of Nursing emphasized the severity of the situation, stating, “If they are retaining urine, they can end up with kidney issues, a bladder rupture, or an infection.” The Primary Physician further elaborated on the potential consequences, saying, “If urine isn’t draining from the bladder into the catheter, it can result in obstructive uropathy and post renal acute kidney injury.
The facility’s policy on “Catheter Care – Urinary” clearly states that staff should “Observe the resident’s urine level for noticeable increases or decreases. If the level stays the same, or increases rapidly, report it to your supervisor.” It also mandates staff to “Observe the resident for signs and symptoms of urinary tract infection and urinary retention. Report findings to the supervisor immediately.”
This incident highlights a critical failure in following established protocols for catheter care, resulting in severe health consequences for the resident. The lack of proper monitoring, assessment, and timely intervention led to a preventable hospitalization and put the resident at significant risk.
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