Failure to Change Urinary Catheter and Notify Physician of Abnormal Findings
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of urinary retention, hemiplegia, and cerebrovascular accident did not have his urinary catheter changed according to the physician's order. Observations revealed that the resident's catheter bag contained dark, foul-smelling urine with visible sediment and mucus, and the room had a strong odor of urine. Staff interviews confirmed that these were signs of a possible urinary tract infection (UTI) and that such findings should be reported to nursing staff for further action. Record reviews showed that the physician's order to change the catheter drainage bag on the 15th of each month and as needed was not entered as a scheduled task in the Treatment Administration Record (TAR), resulting in the catheter not being changed as ordered. Nursing staff acknowledged that the presence of sediment and foul odor in the catheter tubing should have prompted a catheter change, physician notification, and further assessment, including a urinalysis. However, these actions were not taken, and the physician was not notified of the missed catheter change or the abnormal findings. The facility's care plan and job descriptions required staff to follow physician orders, recognize abnormal findings, and escalate concerns to the physician. Professional references and guidelines reviewed by the surveyors supported the expectation that nurses follow physician orders unless there is a safety concern, and that failure to do so can be considered neglect. The lack of adherence to these standards resulted in a missed catheter change and failure to notify the physician of potential infection indicators.