Failure to Notify Physician and Family After Resident Self-Removes Foley Catheter
Penalty
Summary
The facility failed to notify the resident's physician and family after a resident with severe cognitive impairment removed his Foley catheter, resulting in bleeding. The incident was observed by a registered nurse, who found the resident standing in his room with blood on the floor and the catheter removed. The nurse assisted the resident with a shower and reinserted the catheter without the resident expressing pain. However, the nurse did not inform the resident's physician or family about the incident, despite acknowledging that such notifications are typically required in these situations. Review of the facility's policy confirmed that staff are required to notify the physician and family in the event of an accident, injury, or significant change in the resident's condition. The resident in question had multiple diagnoses, including dementia, repeated falls, and prostate cancer, and was dependent on staff for most activities of daily living. The failure to notify relevant parties following the removal of the Foley catheter and associated bleeding constituted noncompliance with facility policy and regulatory requirements.