Failure to Notify Physician and Document Catheter Complications
Penalty
Summary
A resident with a history of urinary tract infection (UTI), sepsis, and congestive heart failure was admitted with an indwelling urinary catheter and identified as high risk for developing complications, including UTI. The resident's care plan included interventions to assess for and record any changes in bladder status and to notify the physician of signs and symptoms of UTI. On review, it was found that the resident complained of pain, and a treatment nurse observed sediments in the resident's catheter after removal. However, the nurse did not notify the physician of the observed sediments, did not document the finding, and did not check or record the resident's vital signs, including temperature. The Director of Nursing confirmed that the resident's complaints and the observation of sediments should have been documented and reported to the physician, as per facility policy. The facility's policy required staff to observe for complications associated with urinary catheters, report any complaints of pain, and notify the physician or supervisor of any unusual findings. The failure to document and communicate these findings constituted a deficiency in providing appropriate care and services to prevent urinary tract infections.