HospitalInspections.org

Based on review of medical records, review of policies and procedures and interviews, the hospital staff failed to accurately and completely document the patient's genitourinary (GU) status (removal of Foley catheter and urinary output) on 2-9-11 according to the hospital's policy and procedures.

Patient Identifier (PI) #1, a patient in the Medical Intensive Care Unit (MICU), with a physician order dated 2-8-11 for a Foley catheter and strict intake and output was found not to have any documentation of a urinary output on 2-9-11 on the ICU flowsheet or Summary report for Vitals and/or Fluids. There was no documentation in the Health Notes addressing the removal of PI #1's Foley catheter and if the physician was notified. (PI #1's family member states that the MICU nurse told said family member that PI #1 pulled out his Foley catheter on 2-9-11 before his transfer to Medical Unit). PI #1 was transferred from MICU to the Medical Unit on the evening of 2-9-11 at 19:32. The GU section on the Nursing Transfer Form was not completed (left blank).

The MICU nurse(s) on 2-9-11 failed to document:
1. PI #1's urine output by Foley catheter and/or the number and amount of voids;
2. The removal of the Foley catheter in the Health Notes: and,
3. Complete the GU section of the Nursing Transfer Form.

This deficient practice effected PI #1, one of ten sampled patients.

Findings Include:

1. POLICIES AND PROCEDURES:

Intake and Output: Measuring and Recording Policy # NUR.GEN.051
I. Purpose:
1. To detect any fluid imbalance resulting from discrepancies in amount of fluid taken into the body and the amount lost.
2. To help evaluate the kind and amount of electrolytes and fluid needed to replace the amount lost in output.
3. To assist the physician in the diagnosis and treatment of the patient with a condition in which fluid and electrolyte balance is of paramount importance...
C. Measuring and recording fluid output:
1. Measure the amount of urine and record on the Vital Sign I&O (intake and output) graphic record and in the computer. Record time, type, and amount...

Foley Catheter Policy # NUR.GEN.073
J. Documentation:
In the health professional notes or on appropriate flow sheet, document:
1. Time of catheterization.
2. Name of person performing catheterization...
6. Time of removal / replacement of indwelling catheter.
7. Site and type of catheter used...

Foley Catheter Removal Protocol 1583-PO-GEN-42 9/10
(Protocol approved by PI (performance improvement) Council and Medical Executive Committee)
PHYSICIANS ORDERS
Foley catheter meets none of the below criteria and must be removed.
*Urologist is consulted on case or is the admitting physician.
*A Physician has ordered that the catheter not be removed.
*A Physician has documented medical necessity within the past 24 hours.
*The patient is unresponsive.
*The patient is receiving palliative or hospice care.
*The patient has received IV sedation within the past 12 hours.
*The patient has received IV inotropic agent with the last 24 hours.
*There is an order for IV diuretics to be given every six or fewer hours.
*The patient is undergoing ultrafiltration.
*Acute or worsening renal failure is evident by a creatinine level increase of 1 mg/dl or more above the admission or baseline level.
*Surgery has been performed within the last 24 hours.
*A pressure ulcer or surgical wound might be soiled if the catheter is removed and the patient is incontinent.
*Implemented by ___ (Nurse Signature).

Patient 24-Hour Assessment / Flowsheet 1583-M-05-1052 2/09
This is a record of the patient's status. Place initials in each pertinent box. If no personal notation is made, it means that no unusual observations were made, no unusual activities, or no incidents occurred and the previous documented status exists.
NOTE: Although the above instructions are not printed on the ICU (Intensive Care Unit) Flowsheet, it is implied that this is the policy for nursing documentation in the ICUs throughout the hospital.

Transfer, Between Patient Care Areas Policy # NUR.GEN.043
I. Policy Statement:
The patient will safely and effectively be transferred upon request from patient, upon order by physician, and/or condition warrants...
D. Procedure:
1. Transfer within the same unit or to another unit (except critical care).
a. Give report to receiving nurse including need for any special equipment.
b. Transfer patient via bed or wheelchair...
c. Transfer patient's belongings and equipment...
d. Complete transfer summary form if transferring to another unit.

2. RECORD REVIEW:

PI# 1 was admitted from a skilled nursing facility (SNF) through the emergency department to MICU on 2/06/11 with diagnoses including: Hyponatremia, seizure disorder, hypokalemia, Parkinson's disease, anemia, debility, bipolar disorder, dementia, chronic airway disease, history of Fournier's gangrene with bilateral testectomy 20 years ago, Fournier's gangrene with incision and drainage of left groin area on 2-12-11, pneumonia, acute on chronic respiratory failure... PI #1 expired in the hospital on hospice care on 3-3-11.

On 2-8-11 at 10:40 AM Physician Orders for PI #1 include:
1. Foley Catheter.
2. Strict I/O's (intake/output)...

On 2-9-11 at 07:30 AM Physician Orders for PI #1 include:
1. Transfer to medical bed on floor (7th)...
3. Cont. (continue) all other Rx (prescriptions)...

For the date of 2-9-11 there is not a Physicians Orders Foley Catheter Removal Protocol signed and dated by the MICU Nurse (Employee Identifier #1). Lack of this physicians order could be interrupted as the nurse did not remove the Foley catheter but rather the patient removed (traumatic) his Foley catheter.

Review of PI #1's ICU Flowsheet dated 2-9-11 documented the following for GU:
0700 Description of urine - A (amber). Foley/Voids - F (Foley).
1100 Description of urine - A. Foley/Voids - F.
1500 Description of urine - A. Foley/Voids - V (Voids).
1900 Description of urine - A. Foley/Voids - V.

On the ICU Flowsheet (2-9-11) it is noted that the Family / so (significant other) interaction blocks are blank (no documentation of visit from family / so, nurse initiated contact with family / SO, emotional support given to family / so, family conference with physician...).

On the ICU Flowsheet (2-9-11) it is noted that the Output section is blank, without documentation in the blocks for Urine hr (hour) / Cumulative output.

On Summary report for Vitals and/or Fluids for 2-9-11 it is noted that the Output section is blank, without documentation in the blocks for Void and Cath (catheter) for Days, Eves (evenings), Nights, and Total (24 hour total).

Review of the Health Notes for 2-9-11 revealed that there was no documentation by the MICU nurse(s) for the above date.

The Nursing Transfer Form for PI #1 being transferred from MICU to the Medical Unit dated 2-9-11 and timed 19:32 was reviewed. The Nursing Transfer Form was completed in all sections except the GU section which was blank. The GU section lists the following items to be addressed:
Foley catheter.
Incontinent.
Voiding.
Date Foley inserted ___.
Date Foley changed ___.

3. INTERVIEWS:

PI #1's family member (interviewed on 7-6-11 at 2:05 PM) verified that the MICU nurse (EI #1) had said that (PI #1) pulled out his Foley catheter and that (she/MICU nurse) was not going to put the catheter back in (on 2-9-11), and that PI #1 was being transferred to the Medical Unit. PI #1's family member said that this (removal of Foley catheter by the patient) was not communicated to the physician or the receiving staff nurse on the Medical Unit...

Employee Identifier (EI) #1 (MICU nurse on 2-9-11 7 AM - 7 PM) was interviewed over the telephone on 6-30-11 at 1:20 PM. EI #1 stated "I don't remember him (PI #1) pulling his catheter out... He (PI #1) pulled the diaper off (after Foley catheter was out) and I changed it... It (diaper) was wet, that's why he pulled it off. I didn't move him (PI #1) out (transfer to 7 Main) on my shift because the room wasn't ready. I do know I gave report to (EI #2) and told him to check the patient, that he was peeing okay..."

EI #2 (MICU nurse on 2-9-11 7 PM - 7 AM) was interviewed over the telephone on 6-30-11 at 5:00 PM. EI #2 stated that he was unable to recall anything about PI #1 or his transfer to the Medical Unit on the evening of 2-9-11.

DI #1 (Attending Physician/Hospitalist) was interviewed over the telephone on 7-1-11 at 2:40 PM. DI #1 stated "I wasn't told (PI #1) pulled out his Foley catheter which can cause hematuria, tears..."

EI #5 (MICU Director) was interviewed in person on 6-30-11 at 1:50 PM and on 7-1-11 at 10:20 AM. EI #5 stated "(PI #1 was not normal down there (perineal area), had some surgery (bilateral testectomy)... When he (PI #1) was admitted from the SNF he had a condom catheter on 2-6-11 and 2-7-11. On 2-7-11 he wore a diaper, then had a Foley catheter (2-8-11) for, it looks like, 24 hours. Then no Foley catheter on 2-9-11 and he (PI #1) voided before he was transferred out (of MICU). Our policy is charting by exception in the Health Notes... There is not a place to put the time on the flowsheets when the Foley catheter was pulled (removed) so the nurses know when the patient is due to void (eight hours after the catheter was removed)... I didn't know until yesterday (6-30-11) that the Nursing Transfer Form (for PI #1) wasn't completed for the GU section. I started with my nurses yesterday about completing the Nursing Transfer Form..."

EI #3 (Medical Unit Nurse on 2-9-11 on 7 PM - 7 AM) was interviewed over the telephone on 6-30-11 at 2:40 PM. EI #3 stated "They (MICU Nurse) did give me a report, that his (PI #1) Foley had been pulled out and he (PI #1) had voided before he was transferred (from MICU to Medical Unit). We checked his diaper frequently..."

EI #4 (Medical Unit Nurse on 2-11-11 on 7 AM - 7 PM) was interviewed in person on 6-30-11 at 2:10 PM. EI #4 stated "...In (shift) report (from 7 PM - 7 AM on PI #1) I was told that the nurse (MICU) said the patient had pulled it (Foley catheter) out and the doctor wanted it (Foley catheter) left out."

EI #6 (7 Main Director) was interviewed in person on 6-30-11 at 3:15 PM and on 7-1-11 at 10:45 AM. EI #6 stated "(EI #1) said that she got report (from MICU Nurse) that (PI #1) had pulled out his catheter in MICU... Since (PI #1) hospitalization the Foley Catheter Policy was revised to include bladder scanning which has decreased our Foley catheter use and infections (urinary tract infections). We piloted the Indwelling Urinary Catheter Flow Sheet on my floor (7 Main), made some revisions and will start using this flow sheet the day after the 4th of July (7-5-11). This flow sheet includes documentation for the appropriate indications for the Foley catheter, the insertion of the catheter, maintenance and daily care, reasons to continue the catheter and when the catheter was discontinued..."

This citation is written as a result of the investigation of complaint AL00024471.