Failure to Assess Catheter Removal and Coordinate Urology Follow-Up
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter was properly assessed for catheter removal and that timely coordination with urology occurred. The resident, who was admitted with a history of stroke and kidney disease and was severely cognitively impaired and dependent for activities of daily living, had an indwelling catheter placed during a hospital stay due to severe diaper rash. After discharge, the resident was placed on hospice, and the catheter remained in place. When the resident was no longer on hospice, there was no documentation that the facility reassessed the need for the catheter or consulted with urology regarding its continued use. Collateral contacts, including a family member, repeatedly expressed concerns to facility staff about the resident's catheter, specifically noting frequent red urine and the presence of sludge in the catheter bag. Despite these ongoing concerns and repeated documentation by the medical provider requesting clarification and follow-up with urology, there was no evidence in the medical records of communication or follow-up with the urology office until several months later. The care plan continued to list the indwelling catheter for obstructive uropathy, but no action was taken to reassess or attempt removal. Eventually, after the family contacted the urology office directly, an appointment was scheduled, and the urologist requested a catheter change and urinalysis prior to the visit. When the catheter was changed, the resident was found to have red urine and was sent to the emergency room, where a catheter-associated urinary tract infection was diagnosed and treated with intravenous antibiotics. The facility's Director of Nursing confirmed that there was no documentation of assessment for catheter removal or timely urology consultation after the resident came off hospice.