TULSA, OK – LEISURE VILLAGE HEALTH CARE CENTER

Based on observation, interview, and record review, it was determined the facility failed to assess and monitor the use of an indwelling urinary catheter, and/or to provide catheter care and catheter changes as required for three (#1, #3, and #4) of three residents with indwelling urinary catheters. Resident #1 required hospitalization [MEDICAL CONDITION] and a complicated urinary tract infection.

A nurse’s note, dated 10/08/19 at 1:30 a.m., documented, Notified by aide that resident was not responding to assistance.

Upon arrival to room, resident lying in bed with both arms raised above head in a fixed position and mouth open and twitching. Resident slow to respond to questions when trying to determine level of orientation. Displayed increased confusion and A&OX1 TO SELF. Resident just cont to repeat his name .Notified Dr. (name deleted) and adv (advised) to send resident to ER for further evaluation

The emergency department triage nurse progress note, dated 10/08/19, documented, .Pt from Leisure Village. Tonights nurse reports decreased L[NAME] from pt norm approx 2200 tonight. At midnight pt was Aox1 and more lethargic than normal .Pt has new onset of tremors. Decreased UOP and decreased [MEDICAL CONDITION] output. Pt also had one episode of ‘thick/clear vomitus. It came out of his mouth and made a splatter noise when it hit the ground.’ According to EMS crew .[MEDICAL CONDITION], foley in place. Foley has ‘8/29 dated on foley collection bag.’ Leaking noted around catheter .

The emergency department nurse’s progress note, dated 10/08/19, documented, .Pt foley removed. Pt had bloody, pus drainage from penis. Cleaned with green wipes. Foley replaced .Thick. tenacious, blood tinged/gray/red urine dranage noted in foley tubing >1100 ml noted and continuing to flow .Pt foley has total of 1500 ml of red colored urine. Pt foley flushed with 30 ml of flush, returned into catheter bag. Drainage light red in color. Clots noted .

The emergency department physician’s progress note, dated 10/08/19, documented, .He has an indwelling Foley catheter. Material is very exudative and appears to be pus. This catheter was removed and a significant amount of puslike material was found .Following the pus that withdraws drain was then hematuria that was manually irrigated with 30 cc and is now clearing .He is found to have acute [MEDICAL CONDITION] that I suspect is postobstructive secondary to urine was not draining .

The hospital discharge summary, dated 10/16/19, documented the resident had a complicated urinary tract infection associated with his indwelling urinary catheter caused by Proteus mirabilis.