Failure to Provide Appropriate Catheter Care and Notification
Penalty
Summary
A resident with a history of acute kidney injury, obstructive uropathy, urogenital implants, urinary retention, and dementia was admitted with an indwelling urinary catheter. Upon admission, there were no physician orders for routine catheter care, and the comprehensive care plan did not address the presence of the catheter or include related goals and interventions. The hospital discharge summary indicated the need for a voiding trial and scheduled catheter change, but only an order for monthly catheter change and urology follow-up was documented, with no specific instructions for ongoing catheter care. Shortly after admission, the resident was found attempting to remove the catheter and was later discovered to have pulled it out. Attempts to reinsert the catheter were unsuccessful due to the resident's resistance, and the supervisor was notified. Documentation in the 24-hour report sheet reflected the removal and refusal of replacement, but the medical team was not notified of the incident at the time. Subsequent nursing and medical progress notes did not mention the catheter or its removal, and the resident was later transferred to another unit without a catheter. Interviews with nursing staff and providers revealed that catheter care should have been ordered and included in the care plan upon admission. The physician was unaware of the catheter removal and stated they should have been notified. The DON confirmed that the care plan and orders were incomplete and that the provider should have been informed when the catheter was pulled out and could not be reinserted. The lack of appropriate orders, care planning, and timely provider notification led to the deficiency.