Failure to Notify Physician of Catheter Site Infection Signs
Penalty
Summary
The facility failed to notify the physician of signs and/or symptoms of a potential infection at the urinary catheter entry site for a resident with an indwelling urinary catheter. According to the facility's policy, nursing staff are required to document a comprehensive assessment and notify the physician when infection is suspected, including providing details of the assessment, observed symptoms, and the time symptoms were first noted. The resident in question had a history of urinary retention, congenital bladder neck obstruction, and recurrent urinary tract infections, and was cognitively moderately impaired. Physician orders were in place to monitor the catheter site for infection and report any signs to the physician. Despite multiple nurse notes documenting odorous brownish and tannish brown drainage from the catheter site over several days, there was no documentation that the physician was notified of these symptoms. Interviews with nursing staff confirmed that the physician should have been notified, but there was no record of such communication. The resident was later admitted to the hospital for a complicated urinary tract infection and hypotension, and the planned suprapubic catheter placement was not performed at that time.