Failure to Provide Urology Consultation Following Failed Voiding Trial
Penalty
Summary
A deficiency occurred when the facility failed to ensure a urology consultation was provided for a resident with multiple complex diagnoses, including Type 2 Diabetes Mellitus with hyperglycemia, neuromuscular dysfunction of the bladder, infection and inflammatory reaction due to an indwelling urethral catheter, and chronic kidney disease. Upon admission, there was a verbal order to consult urology for urinary retention, and the ARNP documented in progress notes that a voiding trial should be initiated, with instructions to consult urology if the trial failed. Despite these instructions, the voiding trial was either not performed as ordered or, when eventually conducted and failed, the required urology consult was not arranged. Interviews with facility staff revealed miscommunication and lack of follow-through regarding the urology consult order. The DON acknowledged that the ARNP had requested a voiding trial and a urology consult if the trial failed, but stated that the ARNP did not enter the consult order into the system. The ARNP, however, reported that she verbally instructed both the DON and the Unit Manager on multiple occasions to consult urology after the failed voiding trial. The facility did not have a policy or procedure in place regarding care consultation and referral, contributing to the failure to secure the necessary specialist evaluation for the resident.