Failure to Notify Responsible Party of Catheter Dislodgement and Replacement
Penalty
Summary
The facility failed to notify a resident's responsible party when a significant change in condition occurred involving the dislodgement and replacement of a urinary catheter. The resident, who was admitted under hospice services for respite care and had severe cognitive impairment along with multiple diagnoses including degenerative disease of the nervous system, dementia, Alzheimer's disease, hypertension, and chronic kidney disease, stood up unassisted and pulled out her urinary catheter. Facility nursing staff immediately contacted hospice services, and a hospice nurse reinserted the catheter without difficulty. Documentation indicated that the dislodged catheter balloon had not been fully inflated as required. Despite the incident and the facility's policy requiring notification of the resident's legal representative in the event of a significant change in condition, there was no evidence that the responsible party was informed about the catheter incident. The facility Administrator believed hospice services had notified the family, but the Hospice Executive Director confirmed that the family had not been notified. The facility's policy also required documentation of notification or attempts in the resident's electronic health record, which was not present in this case.