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Based on review of facility Medical Staff Rules and Regulations, medical record review, and interview the facility failed to ensure a Urology consult was completed for 1 patient (Patient #1) of 1 patient reviewed with an indwelling urinary catheter of 5 patients reviewed.

The findings include:

Review of the facility's Medical Staff Rules and Regulations, undated showed "...If circumstances are such that the consulting physician determines that the consultation is not required for patient care, the consultation shall not be performed and the reason for such shall be promptly documented in the progress notes of the patient's clinical record. It is recommended such decision be discussed with the provider requesting the consultation...All requests for consultation shall state the time frame within which the consult should be accomplished. There are three (3) established time frames for providers to respond to requested consultations...Routine - responds within 24 hours of consult being called..."

Medical record review of a History and Physical showed Patient #1 had been transferred to the facility with a Non-ST-elevation myocardial infarction (partial blockage of the coronary arteries, causing decreased flow of oxygen to the heart) on 12/8/2022. The patient had a history of Type 1 Diabetes Mellitus, with long term current use of insulin pump, Stage 3 Chronic Kidney Disease/Solitary Kidney (1 kidney), Hypertension, Hyperlipidemia, Cerebrovascular Accident, and Right Nephrectomy (removal of kidney)/Benign (non-cancerous) Tumor.

Medical record review of a Cardiothoracic (surgeon specialized in the chest and heart) Surgery Operative Report showed Patient #1 had Coronary Artery Bypass Grafting (CABG-a surgical procedure to improve blood flow and oxygen supply to the heart) on 12/14/2022.

Medical record review of a Hospitalist (medical doctor who works only in a hospital) Daily Progress note dated 12/17/2022 showed Patient #1 had urinary retention (unable to empty the bladder of urine). A straight catheterization (tube inserted into bladder to drain urine and immediately removed) was performed. The plan was to repeat a bladder scan (procedure to determine the amount of urine left in the bladder after urination) and to potentially consult Urology (a doctor who specializes in conditions that affect the urinary tract).

Medical record review of a Hospitalist Daily Progress note dated 12/18/2022 showed Patient #1 had an indwelling urinary catheter (tube placed in bladder and left in place) inserted due to urinary retention. Urology was consulted.

Medical record review of Physician Orders showed a Urology consult was ordered for Patient #1 on 12/18/2022 at 10:30 AM.

Medical record review of a Physician Notification form dated 12/18/2022 at 3:49 PM showed a Registered Nurse (RN) spoke with the Urology Office regarding the consult for Patient #1.

Medical record review of a Cardiothoracic (Advanced Practice Nurse-APN) Daily Progress note dated 12/19/2022 at 6:35 AM showed "...Await pending urology consult for urinary retention. [Named indwelling urinary catheter] replaced yesterday and flomax [medication used to treat urinary problems] started. Likely will DC [discharge] home with [named indwelling urinary catheter] in place and outpatient follow up but given holiday week, will be sure this will be ok and they are able to see the pt [patient] in the office. Pt with a history of prostate issues in the past, prostatitis [inflammation of the prostate gland], BPH [benign prostatic hypertrophy-enlargement of prostate]...Will plan discharge home today pending that consult and input from urology..."

Medical record review of a Nursing Communication Order entered by an APN on 12/19/2022 at 10:15 AM showed "...please clarify Urology plans prior to discharging pt. Uro [urology] consulted yesterday for urinary retention and [named indwelling urinary catheter] replaced..."

Medical record review of a Nursing Provider Notification dated 12/19/2022 at 2:00 PM showed a RN contacted the Urology office and notified them Patient #1 had been discharged by Cardiothoracic Surgery but still needed to be seen by the Urologist.

Medical record review of Patient #1's Discharge Summary dated 12/19/2022 at 2:52 PM showed the indwelling urinary catheter remained in place. "...await urology consult and input. Plan DC home this afternoon with [named indwelling urinary catheter] as long as ok with urology. Plan for outpatient follow up in their office...F/U [follow up] with Urology, [named urologist], next week for voiding [emptying bladder] trial and [named indwelling urinary catheter] discontinuation [removal]..." The discharge disposition showed the patient was to be discharged to "...Home or Self Care...ok to dc home once urology plans clarified..."

Medical record review showed a Urology Consult note was not in Patient #1's medical record.

During an interview on 1/10/2023 at 11:30 AM, in the conference room, the Clinical Improvement and Compliance Coordinator, confirmed a Urology Consult note was not in Patient #1's medical record. The Clinical Improvement and Compliance Coordinator agreed there was no documentation to show a Urology Consult was completed for Patient #1 as ordered and agreed the facility failed to follow the Medical Staff Rules and Regulations for consults.

During an interview on 1/10/2023 at 1:50 PM, in the conference room, RN #1 stated a Urology Consult had been ordered for Patient #1 the day before he was discharged. The patient had been released by Cardiothoracic Surgery but was waiting for the Urology Consult to be completed before he was discharged. RN #1 contacted the Urology Office because it had been over 24 hours and the Urology Consult had not been completed. She stated the Physician's Assistant or Nurse Practitioner called her back and said Patient #1 already had an appointment scheduled for the next week and "...gave the go ahead to discharge..." the patient. Patient #1 was discharged late in the evening without being seen by a Urologist. He was discharged with an indwelling urinary catheter in place.

During an interview on 1/10/2023 at 2:02 PM, in the conference room, the Cardiothoracic Surgical Unit Supervisor stated Urology would often call and check on patients. If an indwelling urinary catheter had been placed for urinary retention and the patient was not having problems, it was not uncommon for Urology to just have the patient follow up with them in the office.

During a telephone interview on 1/10/2023 at 2:50 PM, a Cardiothoracic Surgery PA confirmed Patient #1 had an indwelling urinary catheter for urinary retention and confirmed Urology had been consulted for the patient. Patient #1 waited all day to be cleared by all physicians and needed clearance from the Urologist to go home with a urinary catheter. The PA stated it was common for Urology to call and direct staff to leave the indwelling urinary catheter in place and have the patient to follow-up in the Urology Office.