Complaint Investigation Report

An interview on 7/9/24 Licensee stated R1 is uncooperative with staff when they want to drain the catheter bag, staff will leave R1 and return a little later to try again. It was stated caregivers try to check bag every 1-2 hours. Licensee stated nurse told staff the tube was “kinked” and that is why it was not draining.

Interview with S2, S2 stated the morning of 6/26/24 R1 was agitated and when they touched R1’s stomach they noticed there was pain. Staff informed F1 of the agitation, and f/c not draining. S2 believed that F1 would call and inform Home Health of the change of condition. Facility staff now understand to call Home Health directly with change of condition and will notify family as well.

During scheduled Home Health visit on 6/26/24, Home Health documented the following: that R1 had “increase anxiety and agitation”. “…f/c appears to be intact, however is not draining any urine and f/c drainage bag is empty. F/C balloon was deflated, and f/c was removed…new f/c was inserted with return of dark grey and yellow cloudy/milky colored urine.” “…1200cc of urine was drained from patient’s bladder within 15 minutes.” “When abdomen is palpated, patient hollers out in pain, and when f/c is removed, patient yells out in pain. Once f/c is changed, patient has no further complaints or signs /symptoms of pain.” “Abdomen is distended and firm and painful with palpitation per patient.” “Staff unaware there was no urine draining into f/c drainage bag”. Notes on 6/26/24 are the first notes where R1’s pain is noted.

Prior notes provide the following history: 3/19/24 from Home Health Nurse 1 (HH1) states Home Health Staff 2 (HH2) “is finishing treatment as I arrive today. [HH2] informs me that the staff at the RCFE do not know how to manage [R1’s] catheter, and it keeps pulling loose the way the staff is managing it.” 3/19/24 HH2 notes, “Teaching was provided to Family Member 1 (F1) and Staff 2 (S2) as neither knew how to properly place these devices…S1 and [F1] Verbalized Understanding of all education provided today.” On 4/27/24 – “R1 continues to “mess” with [R1] f/c and drainage bag…Upon assessment of f/c, it is noted that patient f/c bag is placed to posterior leg versus anterior leg and each time patient rests leg against something, the clasp of the drainage bag pops open thereby causing leaking. It is also noted that the leg strap securing patients f/c is placed too low on the thigh which is causing the f/c to pull which might be irritating or painful to patient.”

In interview with Licensee conducted on 7/9/24 and during annual visit on 10/24/24, LPA inquired about training documents specific to home health requests.