Failure to Notify Physician After Resident Pulled Out Urinary Catheter
Penalty
Summary
The facility failed to immediately notify the physician when a resident experienced a significant change in condition, specifically after the resident pulled out their urinary catheter. According to the facility's policy, staff are required to document changes in condition and contact the physician to determine the need for medical intervention. In this case, the resident, who had diagnoses including acute pyelonephritis, multiple sclerosis, and stage four chronic kidney disease, was found with the catheter removed and blood on the bedding. There was no documentation in the medical record that the physician was notified of this incident, despite the care plan indicating the provider should be updated as needed. Interviews with facility staff revealed that the nurse assigned to the resident at the time of the incident was no longer employed, and attempts to confirm whether the physician had been contacted were unsuccessful. Other nursing staff were unaware if the physician had been notified and indicated that the catheter was not replaced due to the trauma caused by its removal. The administrator and DON did not recall the incident, and the on-call provider service could not confirm if they had been contacted. The lack of documentation and communication with the physician following the significant change in the resident's condition constituted the deficiency.