Failure to Follow Discharge Instructions for Catheter Removal
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic brain injury, seizure disorder, multiple falls, acute urinary retention with an indwelling catheter, and cirrhosis was admitted to the facility. The hospital discharge summary for this resident included instructions to attempt a voiding trial and remove the indwelling catheter as able after discharge. However, the resident's care plan did not include interventions related to conducting voiding trials or attempting to remove the catheter. Medical record review showed no documentation that nursing staff communicated with urology, attempted a voiding trial, or removed the catheter as directed in the discharge summary. Interviews revealed that the resident was unaware of the reason for the continued presence of the catheter and questioned when it would be removed. Nursing staff interviewed were also unaware of the rationale for the catheter's continued use or why a removal attempt had not been made. The DON stated she was not aware of the discharge instructions regarding the voiding trial and catheter removal, and confirmed that it is facility policy for nursing to review discharge summaries and verify all orders upon admission.