HospitalInspections.org

Based upon interview and record review, the facility failed to ensure emergency care necessary to meet the needs of its inpatients and outpatients was provided regarding appropriate post-discharge services being available and in place for the complaint-focus patient [Patient #1] related to discharge instructions and nursing care after placement of an Indwelling Urinary Catheter in the Emergency Department.
Findings include:

Per record review Patient #1's diagnoses include Delusional disorder and Depressive disorder, and the patient is a resident at an assisted living facility. Per review of Pt. #1's medical record,
the patient was sent to the North Country Hospital's Emergency Department [ED] on 4/16/23
"for urinary tract infection and urinary retention and a Foley catheter was placed." Pt. #1 was discharged on 4/16/23 with the foley catheter and sent back to the assisted living facility. Review of the discharge instructions sent with the patient back to the assisted living facility include the notation that a follow up appointment with Urology should be scheduled "with regards to the Foley catheter that was placed." Further review of the discharge instructions reveal education regarding an antibiotic prescribed for the urinary tract infection, but no education or instructions regarding Indwelling Urinary Catheter Care.

Review of the facility's 'Emergency Department [ED] Discharge/Transfer from the ED' policy (effective 12/1/2016) lists under "Discharge home or to the care of other non-medical personnel" that "The physician will be responsible for writing discharge instructions ...and appropriate pre-printed instructions may also be given to the patient". Additionally, the policy lists "A copy of the instructions are given to the patient to take home."

The day after discharge, on 4/17/23, North Country Hospital [NCH] received a voicemail from Pt. #1's assisted living facility reporting "Patient was seen in ED yesterday, Foley catheter was placed. Nurses at [Pt. #1's facility] are concerned with patient's mood and overall condition."

Review of notes from the facility's Office Clinic dated 4/18/23 record "PT nursing concerns catheter with non-licensed staff ... unsteady gait, falling. (Not skilled nursing) concerned for resident safety with mental status and gait." Notes include "History of Present Illness: The patient is a 72-year-old [patient] who presents at our facility for ED discharge follow up. Pt. has developmental delays and resides in assisted living facility. [S/he] was seen in the ED for urinary retention and hematuria [blood in urine]. [S/he] was discharged with Foley catheter and has not had follow-up. [S/he] complained of pain where urinary catheter exits*. Positive Urinary Tract Infection, unsteady gait and falling are noted ... Pt. was not discharged from ED with nursing care to help with foley, lives in a level 3 ALF [Assisted Living Facility]. Pt has been declining over last few months and having recurrent falls and behavioral issues, likely needs higher level of care."
[Level 3 care is referred to as "enhanced assisted living" because in level 3 care assisted living settings, residents require extensive, hands-on assistance for multiple Activities of Daily Living [ADLs]. If a resident's health continues to deteriorate and requires around-the-clock nursing supervision, the resident will likely move into a Skilled Nursing Facility (SNF) with more specialized, skilled services ...Due to the skilled care and treatment, these services can only be performed by licensed nurses.] (https://experience.care/blog/level-3-care-assisted-living-care-explained/)
The Office Clinic note continues "[Pt.#1] will also need proper foley management and voiding trial, which cannot be done during the last appointment of a clinic day. Given worsening urinary symptoms with recurrent falls and deconditioning, would benefit from ED visit and possible admission. Will also likely need to start the process for higher level of care given that [Pt.#1's ALF] is a level 3."

Physician Progress Notes dated 4/18/23 reveal Pt. #1 was returned to the ED at the request of the patient's Primary Care Physician. ED Physician notes record "Pt. sent in by primary [physician] because [s/he] is not at a SNF (Skilled Nursing Facility) and they feel [s/he] needs a SNF now that [s/he] has a catheter ... Patient was seen at primary care. Pt. is at a level 3 SNF and may eventually need higher level of care. ...Discharge summary from Sunday [4/16/23] had suggested that a follow-up be scheduled with the urologist however this has not been done." The Physician Notes includes an order for a Visiting Nurse "written to help with foley management."
Patient #1 was then discharged back to the Assisted Living Facility on 4/18/23. Per review of Pt. #1's discharge summary, the patient and ALF now received discharge instructions regarding "Indwelling Urinary Catheter Care, Adult", 2 days after the foley catheter was placed and the resident required a return visit to the Emergency Department.

Review of the facility's discharge instructions for "Indwelling Urinary Catheter Care, Adult" reveal a 1400 word document that includes information regarding risks, how to wear the catheter and drainage bag, how to care for the skin around the catheter, caring for the patient's skin and catheter, how to empty the drainage bag, how to change the drainage bag, along with instructions to contact a health care provider if listed signs and symptoms, including "get help right away if: pain where the catheter enters your body"* occur.

An interview was conducted with the Director of facility's Emergency Department [DED], Quality Management staff [QM], and Clinical Applications Analyst [CAA] on 7/17/23 at 2:30 PM.
The three staff members reviewed Pt.#1's medical record including ED department triage notes, Physician notes, ED Summary notes, Nursing notes, Physician Orders including discharge orders, Discharge Summary notes and Discharge information given to the patient on 4/16/23. The DED, QM, and CAA confirmed that Pt.#1's record indicated that s/he resided in an Assisted Living Facility and required extensive, hands-on assistance for h/her daily care, and that the pt.'s Physician reported concerns that Pt.#1 "was not discharged from ED with nursing care to help with foley". The three staff members confirmed the patient was discharged to a residential care facility with no licensed personnel present, and whose staff were not given instructions by the hospital on how to care for the patient and h/her catheter. The DED, QM, and CAA confirmed that discharge instructions sent with Pt.#1 on 4/16/23, after an Indwelling Urinary Catheter was placed, contained no information regarding care or maintenance of the catheter.