HospitalInspections.org

Based on a review of medical records, facility documentation and an interview with staff, the facility failed to ensure that all patient medical record entries were complete, with regard to the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

Findings were:

Patient #1 was admitted to the facility on 10-30-23 and discharged home on 11-7-23. The patient's discharge orders were entered by the physician on 11-7--23 at 12:30 pm. The orders included instructions to remove the patient's Foley catheter but did not include any medication orders to be filled by an outside pharmacy. The discharging nurse printed out the discharge orders at 3:23 and discharged the patient. The physician then entered an order for a medication to be called in and filled at a nearby pharmacy, although the orders had already been printed and the patient discharged. The medical record contained no documentation that the Foley catheter had been removed or the patient's response to the procedure.

Facility policy MCH 2147 titled "Urinary Catheterization" stated, in part:
"Statement:
MCHS seeks to provide quality and safe care to patients that require the use of an indwelling urinary catheter by ensuring that there is sterile placement, routine maintenance, and early removal of the catheter by providing guidelines for care, specimen collection, and protocols for nurse driven removal.
...
Procedure for Removal:
1) Verify order or authorization of protocol to remove indwelling urinary catheter.
2) Gather equipment needed:
a. Syringe
b. Non-sterile gloves
c. Disposable linen saver
d. Peri care cleanser
e. Washcloths/ disposable wash cloths
f. Graduate container to measure
g. Trash can
3) Explain the procedure to the patient and ensure privacy.
4) Perform hand hygiene.
5) Don non-sterile gloves.
6) Place bed in a comfortable working height and lower side rails.
7) Position patient in a supine or side-lying position.
8) Place the linen saver under the patient's buttocks.
9) Insert syringe into balloon port valve.
10) Allow the pressure within the balloon to force the plunger back and fill the syringe with water. Re-seat the syringe if deflation is slow or no deflation is notice.
11) Remove foley stabilization device.
12) Instruct patient to relax and take slow deep breaths.
13) Slowly pull the catheter out onto disposable linen saver.
14) Measure the amount of urine in the drainage bag.
15) Discard the drainage bag by wrapping in disposable linen saver.
16) Cleanse the perinea! area with approved cleanser.
17) Position for comfort.
18) Raise side rails and place bed in lowest position.
19) Remove gloves and perform and hygiene.
20) Instruct patient to notify nurse of need to void.
21) Document in chart:
a. Reason for removal.
b. Date and time of catheter removal.
c. Amount of urine, color, and odor of urine in collection bag.
d. Difficulty with removal of catheter.
e. Patient's tolerance of procedure."

The above was confirmed in an interview with the CEO and other administrative staff on the afternoon of 12-12-23.