Failure to Obtain Physician Order for Catheter Removal and Inadequate Review of Hospital Records
Penalty
Summary
The facility failed to obtain a physician's order prior to removing an indwelling urinary catheter from a resident who was admitted with a diagnosis of urinary retention. Upon admission, the resident had a foley catheter in place as documented in the hospital records, with clear instructions for follow-up with urology and a recommendation to maintain the catheter due to urinary retention. The resident's hospital discharge summary and transition of care documents specified the need for continued catheterization and prompt outpatient urology follow-up. Despite these instructions, the Assistant Director of Nursing removed the resident's urinary catheter, documenting that there was no qualifying diagnosis, without a physician's order or documented consultation with the resident's physician or nurse practitioner. The Director of Nursing later acknowledged that the hospital documents supporting the need for the catheter were missed during the review process and that the removal should not have occurred without a physician's order. There was no documentation that the facility notified the urologist or the resident's physician about the catheter removal. Following the removal of the catheter, the resident developed abnormal laboratory values, including a significantly elevated BUN, and was diagnosed with a urinary tract infection caused by resistant bacteria. The resident required hospitalization, where a large volume of purulent urine was drained after re-insertion of a foley catheter. The facility also failed to ensure timely urology follow-up as directed in the hospital discharge instructions. The facility was unable to provide requested policies during the survey.