HospitalInspections.org

Based on record review and interview the facility failed to ensure staff followed the facility's policies and protocols for 1 (P [patient]1) out of 1 (P1) patient reviewed for adherence to urinary catheter (catheter placed to drain urine from the bladder) and discharge policies. This deficient practice can lead to the lack of care for patients with urinary catheters.

The findings are:

A. Refer to tag A-0813 for staff not following discharge policies.

Catheter policies:

B. Record review of the facility's policy titled, "Urinary Catheter Placement, Care, Maintenance and Removal" dated 11/2024 on page 6 under, "Catheter Removal" stated, "When the patient no longer meets the indications for an indwelling urinary catheter, the catheter may be removed by a licensed nurse or other qualified staff. See Appendix A Urinary Catheter Removal. . . Following removal of the indwelling urinary catheter, the patient will be monitored for any signs and symptoms of urinary retention [the inability to void]. For suspected urinary retention the patient should be encouraged to utilize natural voiding measures. If the patient is still unable to void within 6 hours, further interventions should be guided by bladder scanning [bedside scan that shows if there is urine in the bladder]. C. Bladder management guidelines for adult patients. 1. The patient will be monitored for spontaneous voiding within 6 hours of catheter removal. . ."

C. Record review of the facility's protocol titled, "Urinary Catheter [UC] Removal Protocol" dated 10/17/2023 under "Procedure" stated, "Step 1: Verify that the patient is an appropriate candidate for removal. If the patient has any of the following, STOP and do NOT proceed with catheter removal. . . Step 2: Does the patient meet criteria for continued catheterization?. . . Step 3: If none of the criteria met, the nurse will proceed with Adult Urinary Catheter Removal Protocol. A. The RN can remove the urinary catheter. The nurse documents in the Avatar [program used in the electronic record to identify lines, access and wounds] on the patient that the urinary catheter was removed, removal reason per protocol. 1. Call the Provider only with questions or concerns. 2. If the Removal Protocol is NOT ordered, call for an order if indicated and remove the Invasive Urinary Catheter. B. Once the urinary catheter meets criteria for removal, but is not removed, the nurse must document in the EHR [electronic health record] under urethral catheter criteria - Other Specified per MD [medical doctor] order- and specify reason for not discontinuing UC in the comments. C. Invasive urinary catheter must [be] reassessed for need daily and must be reported to the Clinical Supervisor and Provider." On page 5 there is a table titled, "Post-Catheter Removal Process" it stated, "After removal of the urinary catheter, the RN assesses and documents the following:
1. The patient is spontaneously voiding
2. The patient is not voiding however is comfortable and expresses no desire to void within 6 hours after the UC has been removed. (Do Not Bladder Scan)
3. A bladder scan should be done for any of the following:
a. Patient is uncomfortable at any time, whether voiding or not.
b. Patient has an urge or tried to void but is unable to do so.
c. Patient is incontinent at any time.
d. Patient is unable to void 6 hours after the UC was removed.
e. Perform a bladder scan on patients with new onset of mental status change or confusion to ensure adequate bladder emptying. . ."

D. Record review of P1's provider note for admission date 05/14/2024 revealed P1 had a urinary catheter placed on admission for acute urinary retention (inability to void). Subsequent provider notes dated 05/14/2024 at 9:45 PM and 05/15/2024 at 12:37 PM did not reveal any discussion of a urinary catheter or indication for continued urinary catheter.

E. Record review of P1's nursing assessment dated 05/14/2024 at 10:10 AM under "Urethral Catheter Criteria Assessment" stated, "Urinary Catheter Removal Protocol order exits: No." There was no evidence of a discussion between the nurse and provider indicating whether the urinary catheter should be continued.

F. Record review of P1's provider note for an emergency department visit on 05/15/2024 at 3:09 PM revealed P1 presented for foley removal. Under "Discussion with Independent Historian" stated, "Paramedics, discharged today with a Foley catheter. The facility he is at stated that they cannot have him there with the Foley. He also would like Foley catheter out."

G. Record review of P1's urinary catheter chart revealed the catheter was removed on 05/15/2024 at 3:18 PM.

H. Record review of P1's "Patient Care Timeline" revealed P1 was discharged on 05/15/2024 at 4:46 PM. There was no verification that 1 was able to spontaneously void prior to discharge after the catheter was removed.

I. During an interview on 11/19/2024 at 12:00 PM with S (Staff) 4, non-clinical, it was confirmed that there was no verification that P1 could spontaneously void.

Based on record review and interview the facility failed to ensure that patients were provided education regarding their diagnosis and discharge condition at discharge for 1 (P [patient]1) out of 3 (P1-P3) patients reviewed for discharge from the hospital. This deficient practice could lead to patients not being prepared to care for themselves at home and could result in a return to the hospital.

The findings are:

A. Record review of the facility's policy titled, "Discharge and Transfer of Patients" dated 11/12/2021 under "Purpose" stated, "The purpose of this policy is to provide for efficient and safe guidelines for patient discharge and transfer through good communication with patient, family, significant others and members of the health care team." Under, "Procedure" stated "A. The patient shall be discharged upon written order of the physician/designee based on the following criteria:. . . 9. Medical support (e.g. catheter, ventilator, IV's etc.) needs addressed. . . B. . . . Written discharge instructions including written patient and family education will be provided to the patient or other service provider."

B. Record review of P1's medical record for the admission date 05/14/2024 revealed the following:

1. Review of the provider's note dated 05/14/2024 revealed P1 presented with shaking for several days. P1 was found to be retaining urine (not voiding) and a foley catheter was placed.

2. Review of the discharge summary dated 05/15/2024 did not reveal urinary retention as a discharge diagnosis and the note by a provider did not reveal any mention that a foley catheter was placed.

3. Review of P1's discharge instructions printed on 05/15/2024 at 1:06 PM under "Diagnoses" it listed urinary retention and under "Done Today" stated, "Insert Foley catheter". The discharge instructions did not reveal any evidence of education on the care of a foley catheter.

C. Record review of P1's provider note for an emergency department visit on 05/15/2024 at 3:09 PM revealed P1 was presented for foley removal. Under "Discussion with Independent Historian" stated, "Paramedics, discharged today with a Foley catheter. The facility he was at stated that they cannot have him there with the Foley. He also would like Foley catheter out." Patient was discharged on 05/15/2024 at 4:46 PM.

D. During an interview on 11/19/2024 at 12:00 PM with S (staff) 4, non-clinical, it was confirmed that there was no evidence that P1 or the caregivers received information about being discharged with a urinary catheter.