Failure to Refer Resident with Indwelling Catheter for Urologist Assessment
Penalty
Summary
A resident was admitted to the facility with a urinary retention catheter following a hospital stay, during which the catheter was placed and the resident developed a urinary tract infection (UTI). The resident had a history of heart disease and was alert and oriented at the time of admission. The medical record indicated that the resident was not on a urinary catheter prior to admission and had experienced multiple UTIs and antibiotic treatments since being at the facility. Observations and interviews confirmed the ongoing use of the urinary catheter and repeated episodes of UTIs. Despite the resident's repeated UTIs and continued use of the urinary catheter, there was no evidence that the facility referred the resident to a urologist to assess the necessity of the catheter or to determine the cause of the recurrent infections. The Resident Care Manager confirmed that no referral had been made to obtain further evaluation or orders regarding the catheter's continued use or possible removal. This lack of referral and assessment contributed to the deficiency cited in the report.