Failure to Notify Physician of Catheter Sediment
Penalty
Summary
Facility staff failed to provide necessary care and treatment for a resident with an indwelling catheter by not notifying the physician when sediment was observed in the catheter tubing. The resident had a physician order in place to change the catheter for excessive sedimentation, and both LVN and RN staff acknowledged the presence of sediment and the requirement to report such findings to the physician. Despite this, the physician was not notified, and the catheter was not changed as ordered. The resident involved had multiple diagnoses, including osteomyelitis, diabetes mellitus, and benign prostatic hyperplasia, and required substantial assistance with activities of daily living. Observations on consecutive days confirmed a large amount of sediment in the catheter. Facility policy required notification of the physician for changes in condition, but this protocol was not followed in this instance.