Failure to Follow Up on Urology Referral for Resident with Neurogenic Bladder
Penalty
Summary
The facility failed to follow up on a urology referral for a resident with paraplegia and neurogenic bladder, who was admitted with a Foley catheter and required substantial assistance with mobility and toileting. The resident's care plan included interventions such as monitoring catheter output, changing the catheter monthly, and administering bowel medications as ordered. Hospital discharge orders specifically indicated the need for a urology appointment due to bladder spasms and urine bypassing the Foley catheter. Despite these orders, interviews and document review revealed that the Health Unit Coordinator (HUC) did not schedule the required urology appointment and was unable to provide a reason for this omission. The process for entering and verifying discharge orders involved both the HUC and nursing staff, with responsibilities for comparing and clarifying orders upon admission. However, the Director of Nursing (DON) confirmed that there was no record of a completed or scheduled urology appointment for the resident. A facility policy regarding coordination of care was requested but not provided.