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PELL CITY, AL – RESIDENT WAITS 51 DAYS FOR FOLEY CATHETER TO BE CHANGED AND AFTER CRYING OUT IN PAIN

GOLDEN LIVING CENTER – PELL CITY

LOCATED: 510 WOLF CREEK ROAD, NORTH, PELL CITY, AL 35125

GOLDEN LIVING CENTER – PELL CITY 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 CHANGE FOLEY CATHETER IN A TIMELY MANNER

Level of harm – Actual Harm

Based on interviews, record review and review of the facility’s Admissions Orders, the facility failed to ensure Resident Identifier (RI) #1, a resident with a history of UTI’s (Urinary Tract Infections), Foley Catheter (F/C) was changed in a timely manner after the resident was readmitted to the facility with a F/C on 05/20/14. On 06/23/14 an order was written to change RI #1’s F/C. On 07/10/14, 17 days after the order had been written to change the F/C, and 51 days after RI #1 had been readmitted to the facility, the resident was noted to have dark amber urine and sediment in the F/C tubing. RI #1 began to experience pain by crying out when urinating and the F/C was changed at that time.

Continuing:  On 07/24/14 at 3:26 p.m., the surveyor conducted an interview with the DON (Director of Nursing), EI #6. The surveyor asked EI #6, when a resident is admitted to the facility with a F/C, are orders for the care and the changing of the F/C written at that time. EI #6 replied yes. The surveyor asked EI #6 why this was not done for RI #1 when he was readmitted on [DATE]. EI #6 said the nurse who did the assessment was not the one who put the orders in. The surveyor asked EI #6 why an order was written for RI #1’s F/C to be changed every 30 days on 06/23/14. EI #6 said the order was written because the nurse, EI #7, the Assistant Director of Nursing (ADON), was reviewing the chart and noticed that there was no order for RI #1’s F/C. The surveyor asked EI #6 should RI #1’s F/C have been changed at that time. EI #6 replied it depended on what RI #1’s F/C looked like at that time. The surveyor asked EI #6 why EI #7 had written the order for the F/C to be changed every 30 days. EI #6 said that was a facility protocol. The surveyor asked EI #6 did she think leaving a F/C in for 51 days was too long.

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EI #6 replied no. The surveyor asked EI #6 if she thought 51 days was not to long to have a F/C in, why did the facility have a protocol for the F/C to be changed every 30 days. EI #6 replied that was just what the nurses did. On 07/24/14 at 4:40 p.m., the surveyor conducted an interview with EI #7, the ADON. The surveyor asked EI #7 how often were residents F/C changed. EI #7 replied the F/C was usually changed once a month and as needed. The surveyor asked EI #7 should orders be written for the F/C to be changed when a resident is admitted to the facility. EI #7 replied yes. The surveyor asked EI #7 why this was not done when RI #1 was readmitted to the facility on [DATE]. EI #7 said she did not know RI #1 was readmitted back to the facility with a F/C. EI #7 said when she wrote the order for RI #1’s F/C to be changed every 30 days she thought she was updating the order to include the size of the F/C. The surveyor asked EI #7 if she thought 51 days was too long for a F/C to be in if there was orders for it to be changed every days. EI #7 replied if there was an order yes. The surveyor showed RI #7 a copy of the facility’s Admission Order and asked whose admission order were they. EI #7 said the orders are the ones the facility uses when a resident is admitted to the facility. The surveyor asked EI #7 did RI #1 had a history of [REDACTED].#7 replied yes. A review of the facility’s admission orders [REDACTED] The Following orders are needed when admitted to the facility . Foley Cath (Catheter) Orders . They must be changed monthly . On 07/24/14 at 5:35 p.m., the surveyor conducted the exit conference with the Administrator and the DON, EI #6. When asked if there were any questions, EI #6 stated she would like to change her statement given to the surveyor earlier. EI #6 said she wanted to change her answer to yes when the surveyor asked if she felt 51 days was too long for leaving a F/C in. This deficiency was written as a result of the investigation of complaint/report #AL 464.

Personal Note from NHAA 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 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 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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7 Responses to “PELL CITY, AL – RESIDENT WAITS 51 DAYS FOR FOLEY CATHETER TO BE CHANGED AND AFTER CRYING OUT IN PAIN”

  1. michael mcmickens says:

    Priceless! Absolutely PRICELESS !!!

  2. michael mcmickens says:

    Priceless !! Absolutely PRICELESS !!!

  3. martha says:

    Where in the world was the patients family all these fifty one days?????? Makes me sick to my stomach to know that family’s care no more for their loved ones than to put them in a facility and never return to see about them.

  4. Dawn Buckner says:

    I have a heart for elderly people especially those in nursing homes. My Grandmother was in Golden Living in Trussville, AL . She has now passed away. I personally know of so many things that we, our family, journaled during her stay that were NOT handled professionally or correctly. I have thought of volunteering with the Ambudsmens office because these people still have rights and dignity and are due respect!!!

  5. guin hudson says:

    Several years ago my mother was a resident in a nursing home in the birmingham area..when visiting daily I started to notice the same sheets were always on her bed and always in disarray o marked the sheets in a space that was not obvious..after 4 days noticing no change I asked a charge nurse how often sheets were changed . At this time she told me they were changed daily and as needed…I then asked if the director of nursing could go to the room with me..I showed then the sheets with the markings on them..their reply was that they would make sure that her sheets would be changed daily. …

  6. Hospice RN says:

    I’m not defending the SNF…they didn’t follow physician’s orders and deserved to be cited. That being said: Nurses and Facilities need to make an effort to KEEP UP TO DATE on standards of practice…not doing so is lazy and results in unnecessary harm to patients AND citations that could have been avoided.

    Leaving a catheter in for more than 30 days if there are no symptoms is recommended by the CDC now and has been for more than 5 years, so leaving a catheter in without a change for 51 days isn’t the real issue. According to the citation, the SNF nurse changed the catheter as soon as the pt began exhibiting clinical symptoms (sediment and pain) which is well within current standards of practice. The CDC says to prevent catheter related Urinary Tract Infections clinicians should not change catheters on a schedule. In fact they say that: “Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised.”

    http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

    Simply put: Changing catheters every 30 days is an OLD practice that statistically leads to more infections. The SNF nursing staff wrote orders simply because it’s “the way they’ve always done it”…not because it was in the best interest of the patient and not because the change was actually ordered by the physician. If the facility would have simply updated their policies to reflect CURRENT guidelines AND obtained physician’s orders instead of using OUTDATED standing orders, they would have saved themselves the citation and the bad press this article will cause. In fact, they would probably find that residents in their facility would have fewer catheter-related infections and better health outcomes.

  7. Diane Minton says:

    She may not have had any family and sometimes they do just stick family members in nursing homes and forget them

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