Failure to Ensure Timely Urology Follow-Up and Catheter Assessment
Penalty
Summary
A deficiency occurred when the facility failed to ensure timely assessment and follow-up for the removal of an indwelling urinary catheter for a resident admitted with a diagnosis of acute urinary tract infection and urinary retention. The hospital discharge paperwork specified that the urinary catheter, placed prior to admission, needed to be changed every 30 days and that a follow-up appointment with a urology specialist was required. Despite these instructions, there was no documentation in the resident's medical record indicating that a urology consult had been scheduled or that any interventions for catheter removal, such as intermittent catheterization, had been attempted since admission. Interviews with facility staff, including the DON and the Scheduler, confirmed that no urology consults had been scheduled and no actions had been taken to address the removal of the catheter. The DON stated that the APRN had advised against removing the catheter until a urology consultation occurred, but attempts to contact the APRN were unsuccessful. Review of the facility's clinical protocol indicated that evaluation for catheter removal should have been performed, but this was not documented or carried out for the resident.