IDPH has cited and fined Hickory Point Christian Village when the facility failed to properly monitor a resident’s urinary output and address his urinary retention after his catheter was removed, which led to a severe infection and hospitalization.
The resident in question was admitted to the facility with an indwelling catheter due to urinary retention. The hospital discharge summary noted that the catheter had improved the resident’s renal function and included an order for routine catheter care.
A week later, a certified nurse’s assistant (CNA) discovered that the resident’s catheter was no longer inserted properly and was “free floating” in his pajama pants. The CNA helped the resident use the toilet, and he was able to urinate on his own. The registered nurse on duty informed the resident’s physician about the situation and awaited further instructions.
The physician advised that the catheter could remain out and that the staff should monitor the resident’s urination. However, the registered nurse did not add this as an official order or ask for specific details on how to monitor the resident’s output. The facility discontinued the resident’s catheter care plan but did not replace it with a plan to address his urinary retention or to track his urine output.
Over the next two days, the nurses’ notes did not indicate that the resident’s urination was being properly monitored. Two days after the removal of the catheter, a note mentioned that the resident could urinate freely but did not record the amount. Later that day, another note stated that the resident had voided dark, strong-smelling urine.
By that evening, the resident’s condition had worsened. Another registered nurse noted that the resident was less alert, less responsive, sweaty, had low blood pressure, and increased weakness. The staff called 911, and the resident was transported to the hospital.
At the hospital, the resident was found to have urinary retention, and when a catheter was inserted, a liter of urine containing pus was released. He was diagnosed with septic shock, acute kidney injury, and bacteremia, which is a serious blood infection.
The resident’s physician later stated that the facility should have used a bladder scanner to check if the resident was retaining urine and that the retention likely contributed to his urinary tract infection, kidney injury, and sepsis.
In summary, the facility failed to properly monitor the resident’s urinary output and address his urinary retention after his catheter was removed, which led to a severe infection and hospitalization.
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