IDPH has cited and fined Caseyville Nursing & Rehab Center after a resident there suffered a slit in his penis 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 comes from friction from the catheter and pressure from the tubing and collection device.
The resident in question suffered from numerous health issues and ultimately needed a catheter installed to help him urinate. On a daily basis nurses would have to care for his catheter and the surrounding area.
At first, the catheter made the resident’s penis skin red and sore. There was a care plan made that instructed nurses to watch the spot daily and protect it with ointment. But over many months, the nurses failed to consistently care for the area – oftentimes days would go by without checking the resident’s catheter.
Gradually, a cut formed on the tip of the resident’s penis. The cut grew worse over time and spread all the way down his penis, eventually becoming an open slit. Nurses applied ointment to the cut but did not measure it or keep records of how bad it was getting.
One key mistake was that a nurse incorrectly thought the resident was in hospice. Hospice is limited to comfort care for people near the end of their lives. In hospice the goal is not to heal injuries. So that nurse claimed since the resident was supposedly in hospice, he was not sent to the ER to get the worsening penis slit the medical care it required.
In reality, however, the resident had been removed from hospice care approximately 10 months beforehand. A hospice supervisor confirmed that there was no record of any penis injury for the resident while he was receiving care in hospice. So the resident could (and should) have been sent to the hospital to fix the issue at a much earlier date.
The bottom line – months of poor catheter site care allowed the penis wound to increase in size and worsen. Ignoring internal facility rules to check and care for the catheter wound allowed the injury to grow more severe.
Finally, after 8 months, the resident had to have surgery to implant a new catheter and fix the fully split penis.
The situation likely could have been prevented had the nurses been aware of the resident’s hospice status and if the nurses had followed catheter care policies on a consistent basis.
Sadly, the resident endured much needless and preventable pain and suffering.
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