F0580

D

Failure to Timely Notify Physician of Resident’s Change in Condition and Absent Urine Output

Mcleansboro, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to promptly notify the physician of a significant change in condition for one resident with multiple comorbidities, including Parkinson’s disease, unspecified dementia, aortic valve stenosis, dysphagia, urinary retention, benign prostatic hyperplasia with lower urinary tract symptoms, and cognitive communication deficit. The resident had an indwelling urinary catheter and a care plan directing staff to monitor intake and output and to report signs and symptoms of urinary tract infection or urinary retention, including no urine output, altered mental status, and changes in eating patterns. The resident’s MDS showed severe cognitive impairment, and the Treatment Administration Record documented that on one day the resident’s oral intake was minimal (10 ml on day shift, 240 ml on evening shift, and 0 on night shift) and that the resident ate 0% of all three meals.

On the morning of that day, a progress note documented that when staff attempted to get the resident out of bed for breakfast, there was dried emesis of undigested food in the bed, the resident was incontinent of a large bowel movement, and although afebrile, the resident clenched teeth when staff attempted feeding or medication administration. A later note that same day documented that the resident was up in a wheelchair for lunch but continued to clench teeth when staff attempted to feed. The TAR documented 0 urinary output from 10 p.m. that night through 6 a.m. the following morning. Despite these findings of vomiting, loose stools, refusal or inability to eat and drink, and no documented urine output overnight, the nurse on the 7 p.m. to 6 a.m. shift did not notify the physician, stating she believed the resident was sick from overeating the previous day. The nurse passing medications the following morning also did not notify the physician, despite being aware the resident had been sick with emesis and loose stools and had not eaten or drunk that morning.

Later that morning, another nurse documented that the resident was lethargic with a distended and rigid lower abdomen and that there had been no urine output from the indwelling catheter, at which point the physician was contacted and ordered transfer to the emergency department. In the hospital, the resident was noted to be responsive only to painful stimuli, with a distended bladder and no drainage in the catheter bag; bladder scan showed more than 1570 ml, and after catheter replacement, 1850 ml of very malodorous, nearly brown urine with large sediment was drained. The facility’s policies on change in condition and catheter care required prompt notification of the physician and supervisor for changes in medical condition, including decreased or absent urine output and signs of urinary retention or infection. Interviews with the attending physician and urology staff indicated that action should have been taken when decreased or absent urine output was first noticed, and that waiting additional hours before intervention was not appropriate given the resident’s condition and history.