IDPH has cited and fined Piatt County Nursing Home after a resident there suffered a split in his penis from the tip to the scrotum due to poor catheter care.
The use of catheters is discouraged under federal regulations for nursing homes, in large part due to the risk of the development of urinary tract infections. However for males especially, there is a risk of damage to the urethra from prolonged catheter use. A catheter is a thin tube which is threaded through the urethra into the bladder to allow urine to be drained from the bladder. The risk of tearing of the penis come from friction from the catheter and pressure from the tubing and collection device. The use of a catheter should be addressed in the resident care plan.
The resident as admitted to the nursing home with a catheter in place for urinary retention. Despite having a catheter in place on admission, there was no care plan developed with regard to the use of the catheter. One month after admission, the staff documented a split in the tip of the resident’s measuring 1 cm x 0.5 cm. A wound care physician was brought in to address the tear, and he issued orders which included application of petroleum jelly and consult with a urologist.
When a resident develops a wound like this, this represents a change in condition which requires physician notification (which was done). It also requires revision of the resident care plan. This was not done.
When the staff was interviewed by IDPH as part of its investigation, one nurse said that it appeared that the resident had issues at the nursing home where he resided previously. If there was in fact a tear present when the resident was admitted to the facility, the fact that it went unaddressed for a month is troubling as well. When residents are admitted to a nursing home, the undergo a head-to-toe skin assessment, and if that wound was missed not only during that assessment but also during regular catheter care during the first month of the resident’s admission to this nursing home, that is also substandard care. It means that the wound would not have been reported to the physician, it would not have been addressed in the care plan, and there would have been no treatment for it.
The staff applied the petroleum jelly for four days but then stopped because it was causing drainage. However, the staff did not notify the wound care physician and no order was ever issued to discontinue the use of petroleum jelly. The urology consult was scheduled. However, the earliest date for an appointment which could be obtained was nearly two months later. On the day of the appointment, the resident was not able to go to the appointment because his high-backed wheelchair could not fit into the van which was to take him to the appointment. The appointment was canceled and had not been rescheduled as of the time of the investigation by IDPH.
A month after the urology consult was canceled, the attending physician was notified that the catheter has been changed 3 times in one week due to nonpatency (there was a blockage which kept the urine from flowing through the catheter), that the resident had not yet been seen by a urologist, and that the resident’s penis was split down the the scrotum. IDPH arrived a few days later and found that the urine bag was on the floor next to resident’s bed rather than hanging from the rail. The surveyor observed that the penis was filleted open from the tip to the scrotum. When the surveyor asked whether it was sore, the resident replied, “Yes, more than you know.”
There were a number of shortcomings in the care that this resident received:
- If there was in fact a tear present on admission, it was not discovered by the staff during their initial skin assessment or during subsequent care, nor was the wound addressed in the care plan or in treatment orders.
- Care of the catheter was not addressed in the resident care plan.
- The staff failed to follow the physician’s order for the application of petroleum jelly or advise the physician that application of it was causing additional drainage.
- Once the wound was recognized in the facility, care of the wound was not addressed in the resident care plan.
- The staff failed to obtain a timely appointment for the consult with the urologist, failed to make arrangements for proper transportation to the appointment, failed to advise the wound care physician or the attending doctor that the appointment was canceled, and failed to reschedule it.
- Left the urine collection bag on the floor, resulting in additional pressure on the penile tissues.
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