Failure to Document Physician Orders, Catheterization, Hospital Transfer, and Family Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who experienced urinary retention and was subsequently transferred to the hospital. The staff did not document contacting the physician for catheter orders, did not record an attempt to insert a catheter, failed to document the hospital transfer, and did not document notification to the resident's family regarding a change in condition. The facility's own policies required documentation of treatments, intake and output, physician and family notifications, and changes in condition, but these were not followed in this case. The resident in question had a history of chronic obstructive pulmonary disease and benign prostatic hyperplasia, and was moderately impaired, requiring substantial assistance for activities of daily living. The resident reported difficulty urinating, which persisted for several days before any intervention was attempted. Staff interviews revealed that the DON attempted an in and out catheter, which was unsuccessful, and the resident was then sent to the hospital. However, there was no documentation in the medical record of the catheter order, the catheterization attempt, the hospital transfer, or family notification, despite staff stating these actions were taken. Interviews with staff, including the DON and LPNs, confirmed that expected documentation practices were not followed. The DON admitted to failing to enter the physician's orders for the catheter and hospital transfer into the resident's record, and also failed to document family notification. The facility physician did not recall giving a verbal order for the catheter, and there was no evidence of such an order in the records. The lack of documentation was confirmed by review of the resident's progress notes and physician orders, which showed no entries for the events in question.