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“most likely caused by multiple, traumatic catheterizations at the facility”

SIGNATURE HEALTHCARE OF GEORGETOWN

LOCATED: 102 POCAHONTAS TRAIL, GEORGETOWN, KY 40324

SIGNATURE HEALTHCARE OF GEORGETOWN was cited by the DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES for the following deficiencies:

PLEASE NOTE: The following highlighted quoted text is only a portion of the full report/survey submitted by DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES. The full report/survey can be found here.

FACILITY FAILED TO MAKE SURE SERVICES PROVIDED BY THE NURSING FACILITY MEET PROFESSIONAL STANDARDS OF QUALITY.

LEVEL OF HARM –ACTUAL HARM

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, record review, review of the facility’s policy and review of the Lippincott Manual of Nursing Practice, it was determined the facility failed to ensure services provided met professional standards of quality for one (1) of seven (7) sampled residents (Resident #3). When the resident had leakage of urine from around an indwelling urinary catheter on 06/19/16, the nurse did not notify the Physician of the resident’s change in condition, attempted to flush the catheter, and ultimately replaced the catheter without a physician’s orders [REDACTED]. When the resident cried in pain, experienced bleeding, and insisted the nurse remove the catheter, she instructed the State Registered Nurse Assistant (SRNA) to rinse the original catheter which had been removed, then reinserted the non-sterile, used catheter into the resident’s bladder. Later that night, and into the morning of 06/20/16, the resident’s ex-wife noticed a decline in the resident, including lethargy and a lack of urine output, and expressed her concerns to the nurse, who did not address the concerns.

On the day shift of 06/20/16, at the insistence of the ex-wife, Resident #3 was sent to the hospital. Review of the

Emergency Department (ED) record revealed the resident had minimal or no urine output since the urinary catheter was changed the day before, and lab results revealed a severe urinary tract infection [MEDICAL CONDITION]. According to the Urology Consult report, Resident #3 had gross hematuria (large amount of blood in the urine), most likely caused by multiple, traumatic catheterizations at the facility, with subsequent low urine output and acute renal (kidney) failure.

Interview with SRNA #8, on 06/24/16 at 11:30 AM, revealed on 06/19/16 at approximately 1:00 PM, Resident #3 told him that his/her catheter was leaking. The SRNA reported to the Charge Nurse/Licensed Practical Nurse (LPN) #7, who gathered supplies and entered the resident’s room. When SRNA #8 returned to the room, LPN #7 had taken the old catheter out and was in the process of inserting a new one. SRNA #8 said he noticed the new catheter was larger in diameter than the old one, and asked the nurse about it. He said LPN #7 stated the resident required a larger catheter because there was leaking around the smaller one. When the nurse tried to put the new catheter in, the resident cried out, Stop! Stop! and began bleeding. The nurse stopped, obtained another catheter and inserted it. Resident #3 started crying and told the nurse to take it out because he/she couldn’t stand it. SRNA #8 stated, LPN #7 removed the newly placed catheter and handed the original catheter to the SRNA and directed him to rinse it off in the bathroom. The nurse then, reinserted the used catheter and secured it, and left the resident’s room. SRNA #8 knew the pain and the bleeding wasn’t right and stated he meant to report the incident to the DON, but he got busy and did not report it.

Telephone interview with LPN #7, on 06/23/16 at 6:45 PM, regarding the catheter change for Resident #3 on 06/19/16, revealed she made a mistake and was terminated by the facility. LPN #7 stated she put in the wrong size catheter without a physician’s orders [REDACTED]. She further stated when she inserted the larger catheter, the resident bled and she panicked. She did not acknowledge her attempt to flush the catheter when the resident reported leaking around it, or removal of the larger catheter and re-insertion of the used catheter.

Further interview with Resident #3’s ex-wife, on 06/23/16 at 5:20 PM, revealed she was very upset about the problems resident had regarding the catheter. She stated the resident told her the nurse hurt him/her when she changed the catheter. He/she reported the catheter was leaking urine bad, and after the catheter was changed, there was blood all over his/her belly, the diaper, the towel and the pad underneath him/her. The ex-wife further stated she did not know why the catheter was changed; the resident was not having any pain until after the nurse tried to change it. Continued interview revealed Resident #3 told the ex-wife he/she kept telling the nurse she was hurting him/her but she continued. According to the ex-wife, after the incident Resident #3 said he/she felt the needed to urinate, but it hurt, and he/she thought the catheter was clogged. Further interview with the ex-wife revealed she stayed with the resident all night, and the resident had no urine output. She stated the resident reported feeling shaky, like he/she was having a panic attack. Furthermore, Resident #3 complained of pain in his/her chest, arm and back, and wasn’t as alert as normal. The ex-wife reported the resident acted the same way before when he/she had kidney failure; she kept telling the night nurse something was wrong, but the nurse said the resident’s vital signs were fine and did not need to go out to the hospital. The ex-wife decided if the facility did not call the doctor, she would. She reported the day shift nurse on 06/20/16 did call the Physician and made arrangements to send the resident to the hospital. She further stated in the Emergency Department (ED), the nurse told her the catheter from the nursing home was not working and had to be replaced. The ex-wife also stated she was told the resident was very swollen inside, and had blood clots.

Personal Note from NHA – Advocates: NHAA shares with all the families of loved ones who are confined to nursing homes the pain and anguish of putting them in the care of someone else. We expect our loved ones to be treated with dignity and honor in the homes we place them. We cannot emphasize enough to family members of nursing home residents; frequent visits are essential to our loved ones’ well-being and safety. This nursing home and many others across the country are cited for abuse and neglect.

You can make a difference. If you have a loved one living in this nursing home or any other nursing home where you suspect any form of abuse or neglect, contact us immediately.

We can help you and your loved one file a state complaint, hire a specialized nursing home attorney or help you find a more suitable location for your loved one.

Contact us through our CONTACT FORM located on our website here below or on the sidebar or call our toll free hot line number: 1-800-645-5262.

You can make a difference even if your loved one has already passed away.

 

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