Failure to Notify Physician of Worsening Hematuria and Catheter-Related Changes
Penalty
Summary
The deficiency involves the facility’s failure to immediately consult with a physician when a resident experienced a significant change in condition related to an indwelling urinary catheter. The resident was an elderly female with Alzheimer’s disease, diabetes mellitus, chronic kidney disease, neurogenic bladder, anemia, functional quadriplegia, an ostomy, a feeding tube, and severe cognitive impairment. Her care plan identified her as dependent for all ADLs, at risk for anemia-related complications, and at risk for UTIs due to the presence of a catheter, with specific interventions directing staff to monitor, document, and report abnormal urine characteristics and signs and symptoms of UTI to the physician. Physician orders directed that the Foley catheter be changed PRN for signs and symptoms of infection, obstruction, or compromise of the closed system. Progress notes showed that on one date an LVN documented blood-tinged urine draining from the Foley catheter, low blood pressure, and that the physician was notified, resulting in orders for a urinalysis and IV fluids. A subsequent NP note documented dark orange/red urine, a contaminated UA with mixed microbial growth, the resident’s refusal of IV fluids, and plans for repeat labs. However, from that point through several days later, there was no documentation in the electronic health record of urine color, characteristics, or other changes in condition, and the last documented catheter change had occurred weeks earlier. Despite multiple staff observing that the urine had become dark brown to black, foul-smelling, and remained that way for weeks, there was no evidence that the physician or NP was notified of this worsening change in urine appearance. Video footage provided by the family showed CNAs draining a catheter bag on multiple nights, with the urine in the drainage bag and container appearing dark/black and opaque. Hospital staff later described the catheter from the facility as having mold on the balloon, strings of pus on the tip, purulent urine, and a very dark, almost black appearance with a strong odor, and hospital records documented septic shock likely from a UTI with the indwelling catheter draining purulent urine. Facility staff interviews revealed that CNAs and LVNs had noticed the urine as dark, brown, or black and malodorous for weeks, and some believed it had become “normal” for the resident or assumed prior notification had been sufficient. Several nurses acknowledged they did not consistently assess or document urine characteristics, did not follow up on the worsening urine color, and did not notify the physician again despite recognizing that such changes could indicate infection or kidney issues. The ADON, DON, NP, and Administrator all stated that the dark or black urine color seen in the videos was not normal for the resident and that they would have expected immediate notification and follow-up, but this did not occur until the resident became lethargic and confused with low blood pressure and low oxygen saturation, at which point the physician was notified and the resident was sent to the hospital and diagnosed with severe sepsis and septic shock likely due to UTI.
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