The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on interview and record reviews, the facility failed to ensure that a patients ability to self catheterize was assessed and nursing services provided to ensure safe catheterization for 1 of 11 sampled patient. ( Patient # 11)

Findings include:

On 1/20/16 starting at 12:11 PM, an interview was conducted with Patient # 11 and his spouse at the bedside. They were asked about the quality of nursing care/services they had received. The patient directed his wife to speak for him, but nodded his head to confirm statements made by the spouse. The spouse stated, "I am concerned that when the shift changes things are not always communicated to the next shift. For example, he has a bed and chair alarm because he gets confused and tries to get out of bed. He fell on e night and the next morning when they told me, they admitted that they had forgotten to put on the alarm. He has had three strokes that is why he came in again this time. They put the bedside tray next to the wall and he had to wait 40 minutes after he called to get it moved to his bed, so he could eat. I had to remind staff of the constantly beeping IV (intravenous) alarms. I would sleep by his side the first week to make sure he got the care he needed. One Nurse showed me how to press the button to keep it from going off. He used to be able to do intermittent catheterization at home, but since this stroke his bad hand makes it impossible, but the staff insisted that he continue doing his own catherizations. He was self-mutilating himself because he had trouble holding the cath. I came in one morning and saw blood all over the commode. The doctor came in that morning and I begged him to let him have a catheter because the nurses wouldn't help him. The doctor saw the blood and he ordered the catheter that morning. My husband even stopped drinking so he wouldn't have to catheterize as often. He has been left on the bed pan for 40 minutes at times. I would come in and he would tell me that the staff put him on and forgot to tell the next shift when they left." The spouse was visibly upset when she made these statements and the patient nodded his head throughout the conversation confirming what she had stated.

Review of the clinical record of patient # 11 was then conducted with the Nurse Educator and the Unit Manager. Side by side review of the electronic record revealed, Patient # 11 was admitted to the facility on [DATE] for Cerebral Vascular Accident (CVA) with right sided weakness. The physician orders on admission included to straight catheterize the patient as needed. A thorough search of the patient's record did not reveal evidence that nursing staff assessed the patient's ability to self-catheterize and/or that they performed this service for the patient. There was no documentation in the nurse's notes of observations of the patient's ability to self-catheterize. Review of the patients output record reveals the following: on 1/8/16 500 ml voided urine, on 1/9/16 no documentation of output, on 1/10/16 no documentation of output, on 1/11/16 bathroom privileges, on 1/12/16 Foley catheter.
When asked if the patient's ability to self-catheterize should have been assessed, the Nurse Educator and the Unit Manager both confirmed that the facility staff failed to do so and that the nurses should have performed the catheterizations as ordered.