Failure to Monitor and Document Catheter Care and Timely Laboratory Testing
Penalty
Summary
The facility failed to provide appropriate care and services for a resident admitted with an indwelling catheter and bilateral nephrostomy tubes. The resident had a history of bladder cancer, acute kidney failure, and anemia, and was admitted with visible hematuria (bloody urine). Despite physician orders and care plan interventions requiring monitoring and documentation of signs and symptoms of urinary tract infection (UTI) and hematuria, staff did not consistently assess or document the characteristics of the resident's urine output, including the presence and progression of blood in the urine. Multiple interviews with nursing staff confirmed that there was no documentation of urine characteristics in the resident's medical records, and staff acknowledged that this meant the monitoring was not performed as required. Additionally, the facility failed to ensure that a physician-ordered laboratory test for a complete blood count (CBC) was performed on the specified date. The CBC was ordered to be done on a certain date but was delayed by nine days. During this period, the resident continued to exhibit symptoms such as feeling cold and weak, and laboratory results eventually revealed critically low hemoglobin and red blood cell levels. The delay in obtaining the CBC result contributed to a delay in clinical decision-making and necessary interventions for the resident. Observations and interviews revealed that the resident's urine remained dark red and bloody throughout the admission, and this was not reported to the physician as required by facility policy. The care plan was also found to be incomplete, lacking specific interventions for monitoring the presence of blood in the urine. The facility's failure to monitor, document, and report the resident's condition, as well as the delay in carrying out physician orders for laboratory testing, resulted in a deficiency in providing appropriate care and services for a resident with an indwelling catheter and nephrostomy tubes.