Failure to Schedule Urology Follow-Up for Resident with Indwelling Catheter
Penalty
Summary
Facility staff failed to ensure that a resident with recurrent urinary tract infections and severe urethra erosion from prolonged use of an indwelling urinary catheter received care consistent with professional standards. Despite multiple physician and hospital orders for regular urology follow-up and catheter exchanges, staff did not schedule the required follow-up appointments with the urologist. The resident's care plan inaccurately documented the presence of a suprapubic catheter, which was not supported by the medical record, and there was no evidence that the necessary urology appointments were made after hospital discharges or as directed by the physician. Record reviews showed that the resident had a history of obstructive and reflux uropathy, bladder-neck obstruction, cognitive impairment, and required maximum assistance for all activities of daily living. Orders included regular catheter care and exchanges, and hospital discharge summaries repeatedly indicated the need for urology follow-up. However, documentation of these follow-up appointments was missing, and interviews with staff and administration revealed a lack of awareness regarding the missed appointments and the resident's ongoing urethra erosion. Interviews with nursing and administrative staff confirmed that the responsibility for scheduling follow-up appointments and transcribing orders fell to the charge nurse upon the resident's return from hospital or physician visits. Despite these expectations, the required follow-up appointments were not made until prompted by the surveyor's investigation, and the oversight was not identified by supervisory staff. The resident experienced ongoing issues with catheter clogging, leakage, and skin breakdown, further highlighting the lack of adherence to professional standards of care.