Failure to Notify Provider and Manage Urinary Retention During Voiding Trial
Penalty
Summary
The deficiency involves the facility’s failure to follow its acute change in condition policy and physician orders for managing a resident’s urinary retention and catheter care. The resident, an older female with slight cognitive impairment, was admitted with urinary retention, a UTI, and an indwelling Foley catheter. A physician order directed staff to conduct a voiding trial, perform post-void residual (PVR) bladder scans every shift for five days, and, if PVR exceeded 300 ml, to perform straight catheterization and, on the third such occurrence, reinsert a Foley catheter and follow up with a urologist. On one day, bladder scans showed residuals of 450 ml, 700 ml, and 654 ml, and staff performed straight catheterizations that drained significant urine volumes and later reinserted a Foley catheter. During the night shift, an LPN reported that a bladder scan showed a volume over 300 ml, and that after reinserting a Foley catheter it was not draining; another LPN also attempted insertion, but the catheter still did not drain. The first LPN acknowledged that the resident was retaining urine and that she did not contact the physician or urologist despite the inability to drain urine. A second LPN stated that she believed the Foley was not correctly placed and left it in to see if it would begin draining. The morning LPN removed the non-draining Foley, reinserted a new one, and again noted no drainage, but did not notify the MD or nurse practitioner. The nurse practitioner later stated that no one called to report the urinary retention or inability to drain urine, despite the clear voiding trial order. The DON stated that if multiple staff could not reinsert a Foley to drain urine, staff should notify the physician and follow their order. The resident was later sent from a urology appointment to the hospital, where she was diagnosed with urinary retention and sepsis caused by a UTI and admitted to the ICU for intensive treatment.
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