Failure to Obtain Timely Urology Referral for Resident With Ongoing Foley Catheter Issues
Penalty
Summary
The deficiency involves the facility’s failure to obtain a timely urology referral for a resident with a neurogenic bladder and chronic Foley catheter, despite ongoing catheter-related problems. The resident was admitted with an indwelling Foley catheter and had a care plan addressing catheter management, including monitoring for discomfort, UTI signs, and pain. On one occasion, the resident returned from an appointment with the Foley catheter out and reinsertion attempts by staff were unsuccessful due to resistance; the provider was notified and ordered the catheter left out with bladder scans every eight hours. The catheter was successfully reinserted the following day. Subsequently, the resident experienced a large amount of bleeding and blood clots from the penis, and the on-call provider ordered labs and a urine culture. The resident later presented with excessive bleeding and clots around the urinary catheter and was sent to the hospital, where a CT scan showed the catheter tip in the penile urethra with the balloon distended just proximal to the tip. Interviews with nursing staff revealed that the resident’s catheter had been difficult to replace and that staff had ongoing difficulty changing it, with multiple catheter dislodgements and frequent leakage reported over the course of the year. LPNs reported that the expectation was for staff nurses to attempt catheter changes and refer out if unsuccessful, and one LPN stated that the resident was recommended to follow up with urology and have catheter changes done there due to the increased difficulty. Another LPN confirmed that the expectation was to schedule residents with outside providers as soon as possible and acknowledged that this resident did not see urology until many months after the documented catheter complications and difficulties. The surveyors concluded that the facility failed to refer the resident to an outside provider in a timely manner while there was an ongoing urinary catheter issue.
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