Failure to Provide Appropriate Catheter Care and Physician Notification
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including acute pyelonephritis, multiple sclerosis, and stage four chronic kidney disease, was admitted with an indwelling Foley catheter. The facility failed to ensure that appropriate care and services were provided in accordance with professional standards of practice. There was no documented evidence that catheter care was provided, and physician orders for the care, maintenance, or replacement of the Foley catheter were absent. The resident's care plan indicated the need for daily catheter care and monitoring, but these interventions were not supported by corresponding physician orders or documentation of care provided. The situation escalated when the resident self-removed the Foley catheter with the balloon still inflated, resulting in bleeding. The facility physician was not notified of this significant change in condition, and there was no documentation of monitoring the resident's urine output or assessment following the incident. Interviews with nursing staff revealed a lack of communication and follow-through regarding physician notification and care protocols, with staff indicating that they did not contact a provider due to the absence of specific orders and the resident not expressing discomfort. Facility policies for catheter care were in place but did not address unintended catheter removal, and there was no evidence that these policies were followed in this case.