IDPH has cited and fined Elevate Care Country Club Hill after a resident suffered a kidney injury, hypotension, shock and sepsis due to improper insertion of an indwelling urinary catheter.
The resident at issue had an indwelling catheter. An indwelling catheter is a tube which goes up the urethra to the bladder. Once the tip reaches the bladder, urine should begin to pass down the catheter tube. The passage of urine through the catheter is the signature that the catheter has reached the bladder. At that point a balloon at the tip of the catheter should be inflated which holds the opening to the bladder open and allows urine to continue to drain through the catheter.
In addition to the indwelling catheter, the 22-year-old male suffered from multiple medical conditions including traumatic brain injury, tracheostomy, and gastrostomy.
The incident began when the resident’s catheter was leaking urine, so a nurse performed a catheter change, stating that the procedure involved “you insert the tube until you feel like you’re far enough back. After that you insert the water to inflate the balloon.” The nurse reported seeing some initial urine output so assumed correct placement.
However the next day the resident complained of increasing pain and bleeding from the genital area due to the new catheter. A nurse assessed and found bright red blood in the catheter bag. When the nurse replaced the catheter again, she noted “no urine collected into the bag” afterwards. Other signs of trouble emerged including tachycardia to 165 bpm and a distended stomach.
The resident was sent to the ICU from the facility with hypotension, shock and sepsis. Subsequent lab work showed acute kidney injury. A CT scan finally revealed the specific cause – the catheter balloon had been grossly misplaced into the resident’s penile urethra rather than the correct position inside the bladder.
The urology team tried unsuccessfully to replace the catheter due to significant swelling and inflammation from internal trauma caused by the improper insertion and inflated balloon. After much effort, they were finally able to drain 1100 mL of backed up urine once correctly inserted.
The fundamental issue in this case is an issue of poor nursing technique. The nurse who was responsible for replacing the catheter did not use proper technique in placing the new catheter. Further, the facility lacked formal policies reinforcing safe protocols and nursing monitoring which could have prevented such serious harm from improper technique. Failing to identify the compromise of the upper urinary tract led to kidney damage, sepsis and ICU-level intervention. When nurses fail to follow proper technique, this is a form of nursing home abuse and neglect and can be the basis for a civil lawsuit.
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