Failure to Notify Resident's Representative Prior to Catheter Insertion
Penalty
Summary
The facility failed to ensure that a resident's responsible party was involved in the decision-making process prior to the insertion of a catheter. The resident in question was an elderly male with diagnoses including acute prostatitis, benign prostatic hyperplasia, mild cognitive impairment, and a cognitive communication deficit. His face sheet listed family members as emergency contacts, and the care plan indicated it was very important to involve family in care discussions due to his cognitive status. Despite this, when the resident experienced difficulty voiding, the nursing staff obtained a physician's order for a catheter and proceeded with the procedure without notifying or involving the resident's family or legal representatives. Interviews and record reviews revealed that the resident had a BIMS score indicating moderate cognitive impairment and had difficulty communicating his needs. The care plan specifically noted the need to assess the resident's capacity for medical decision-making and to encourage his participation in simple choices. On the day of the incident, the resident repeatedly expressed the need to urinate but was unable to void. After receiving the order for catheterization, the nurse explained the procedure to the resident, who then allowed the catheter to be inserted, despite initially refusing when approached by another nurse. At no point prior to the procedure was the family or the resident's power of attorney contacted, even though family members were present in the facility at the time. Facility policy required notification of the resident's representative or family member regarding significant changes in condition or treatment, and the admissions handbook reiterated this requirement. Both nursing staff and administration acknowledged during interviews that the family should have been contacted before the catheter was placed. The responsible party and family members confirmed they were not notified and expressed concern, especially given the resident's dementia and inability to remember events. The failure to notify and involve the resident's representative in the decision-making process constituted a violation of the resident's rights as outlined in facility policy.