Failure to Provide Discharge Education and Home Health Referral for Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who was discharged with an indwelling urinary catheter (IUC) and multiple medical conditions, including diabetes, heart failure, and urinary retention. The resident required moderate to maximum assistance with activities of daily living and had moderately impaired cognition. Physician discharge orders specified the need for physical and occupational therapy, skilled nursing for medication management, and post-discharge assessment. However, there was no documentation that the resident or their representative received education on the care and maintenance of the IUC prior to discharge. Additionally, the discharge summary indicated that the resident would be set up with home health services, but there was no evidence that a referral for these services was completed. Interviews with facility staff confirmed that no education or training regarding IUC care was provided to the resident or their representative, and the social services director could not provide documentation of a completed home health referral. The home health agency also had no record of a referral for the resident. As a result, the resident did not receive necessary education or home health services after discharge and subsequently required rehospitalization.