Failure to Follow Hospital Discharge Orders for Urinary Catheter Management
Penalty
Summary
A deficiency occurred when the facility failed to follow hospital discharge orders regarding urinary catheter management for a resident with a complex urological history, including hydronephrosis, prostate and bladder cancer, and a recent sacral fracture. The hospital discharge summary specified that the urinary catheter was to remain in place until a follow-up with urology, but facility staff removed the catheter for a voiding trial based on orders entered into the electronic medical record (EMR). This removal was performed despite concerns voiced by the resident and their representative, who were informed by the nurse that the order to remove the catheter originated from the hospital. Within hours, the facility determined that the catheter should not have been removed and reinserted it per the Medical Director’s review of the hospital records. Following reinsertion of the urinary catheter, the resident began experiencing lower abdominal pain and blood in the catheter tubing. Nursing staff observed string-like blood clots and visible bleeding from the urethral meatus, prompting notification of the on-call provider and subsequent transfer to the emergency department (ED). The hospital urologist found that the catheter had not been advanced properly, with the balloon inflated in the prostate, resulting in trauma to the urethra and the creation of a false passage. The resident required cystoscopy for proper catheter placement, constant bladder irrigation, and antibiotics during a week-long hospitalization. Interviews with facility staff revealed that the discharge summary scanned into the EMR did not match the one reviewed by the nursing supervisor and nurse practitioner, leading to the incorrect order for catheter removal. The nurse who performed the removal did not compare the hospital discharge summary sent with the resident to the EMR orders, relying instead on the orders already verified and entered. The Medical Director and hospital urologist both confirmed that the catheter should have remained in place, and the urologist stated that the resident’s history made catheterization particularly difficult, suggesting that reinsertion should have been performed in a hospital setting.