Failure to Notify Physician of Significant Change in Urinary Status
Penalty
Summary
The facility failed to notify the physician of a significant change in a resident's urinary status. The resident, who had an indwelling urethral catheter due to urinary retention and neuromuscular dysfunction of the bladder, was found to have no urine output in the drainage bag, while their brief was wet twice. Further assessment revealed that the catheter was outside the body more than it should have been. The catheter was removed and replaced, resulting in immediate output of 1700 cc of red bloody, odorous, and tan sludge urine. The responsible party was notified, but there was no documentation that the physician was informed of this significant change in the resident's condition. Subsequent physician notes indicated that the resident was later found to be somnolent and not as vocal as their baseline, prompting further laboratory tests. Blood work revealed an elevated white blood cell count and urine tests indicated a urinary tract infection, for which the physician was eventually notified and treatment was started. The Director of Nursing confirmed that there was no documented evidence of physician notification at the time of the initial significant change in urinary status, resulting in a delay in treatment.