Failure to Provide Timely Catheter Care and Urology Consults
Penalty
Summary
The facility failed to provide appropriate health treatment and services to meet the urological needs of two residents. For one resident with a history of heart failure and urinary retention, physician orders required indwelling urinary catheter care and documentation of urine output every shift. However, review of treatment administration records over several months revealed multiple instances where catheter care and urine output were not documented as ordered. Interviews with nursing staff and the Assistant Director of Nursing confirmed that catheter care and output measurement were expected every shift, and that these tasks were not consistently documented in the resident's medical record. Another resident, admitted with hemiplegia following a stroke and experiencing recurrent urinary tract infections (UTIs), had orders for a urology consult and referral to a urologist. Despite these orders, the consult and referral were not carried out in a timely manner. The resident’s family member repeatedly expressed concerns to staff about the need for a urology evaluation due to ongoing UTIs and a suspected prolapsed bladder. Multiple staff interviews confirmed that the family’s requests were communicated, but the scheduling of the urology appointment was delayed, and there was a lack of timely communication regarding the appointment status to both the family and nursing staff. The facility’s process for scheduling and communicating outside medical appointments was found to be inadequate. The staff member responsible for scheduling did not have access to the electronic clinical record and did not consistently update nursing staff about appointment statuses. This led to a disconnect in communication, resulting in delays in care and lack of timely information for both staff and the resident’s family. The Assistant Director of Nursing acknowledged that the process did not meet expectations and that the facility’s policy for catheter care and timely medical consultations was not followed.