Failure to Complete Urology Referral for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a urology referral and appointment were completed for a resident who had been discharged from a general acute care hospital with orders for a urology evaluation, including urodynamics and cystogram, due to a history of urinary tract infection. The resident's admission record indicated diagnoses of benign prostatic hyperplasia, other specified diseases of the bladder, and metabolic encephalopathy. The Minimum Data Set assessment showed the resident was totally dependent on staff for oral hygiene, toileting, and personal hygiene, and had an indwelling catheter in place. Despite documentation in both the hospital discharge orders and facility progress notes indicating the need for a urology referral, the appointment was not scheduled. During interviews, the MDS nurse confirmed that the responsibility for scheduling the appointment rested with the licensed nursing staff and acknowledged that the referral should have been made but was not. The facility's policies required referrals to outside agencies to meet residents' needs and outlined interventions to prevent catheter-related urinary tract infections, but these were not followed in this case.