Failure to Notify Physician of Catheter Complications and Lack of Urine Output
Penalty
Summary
The facility failed to notify the physician regarding significant changes in a resident's urinary catheter status, specifically the presence of red drainage and the absence of urine output during the night shift. The resident in question had a history of urinary retention, benign prostatic hyperplasia, and chronic kidney disease, and was dependent on staff for toileting and other activities of daily living. The care plan and facility policy required staff to monitor for signs and symptoms of urinary tract infection (UTI), pain or discomfort related to the catheter, and to notify the physician of any changes such as no urine output or abnormal drainage. Documentation in the electronic medical record showed that the resident experienced pain, little urine output, and red drainage from the catheter on multiple occasions. Nursing staff changed the catheter several times, noted continued red drainage, and observed a period with no urine output overnight. Despite these findings, there was no documentation that the physician or responsible party was notified about the lack of urine output or the red drainage until later, when the resident exhibited increased drowsiness and was subsequently sent to the emergency room for evaluation. Interviews with staff confirmed that they were aware of the need to notify the physician in such situations, and the facility's policy also directed immediate notification for excessive bleeding or lack of urine output. The failure to promptly notify the physician as required by policy and care plan placed the resident at risk for further complications, as evidenced by the subsequent hospital admission for a UTI.