HospitalInspections.org

Based on observations, interviews and record review the facility failed the nurses did not follow physician's orders to perform an in and out catheter for a patient experiencing urinary retention placing the patient at risk of developing a urinary infection and pain from a distended bladder.

Findings include:

Review of the facility provided policy "Patient Rights and Responsibilities(undated) reflected in part "You have the right to 1. Considerate and respectful care, and to be made comfortable ... 23. You have the right to receive appropriate and medically necessary treatment ..."

Review of Patient #4's medical records reflected a 48-year-old male admitted on 7/20/19. The PATIENT CARE ORDER x Continuous dated 7/20/19 reflected, "Timed voiding every 4 hours. If PVR (post void residual) greater than 350, proceed to I/O (in and out) cath ..."

Review of Patient #4's nursing's notes reflected the following,
7/20/19 at 11:40 am "PT FC FCD (Foley catheter discontinued) at this time."
7/20/ 19 at 11:59 am FUR (urinary residual) 400 ml."
7/20/19 at 3:40 am, "PVR (urinary residual) 810 ml"
7/20/19 at 4:57 am "Patient having ICP (in and out catheter), 1000 ml removed ..."
7/21/19 at 1:00 am, "Patient retaining urine. PVR revealed >900 ml. Procedure explained to patient. Patient straight-cathed for 8 Fr. 200 ml of urine removed. Patient tolerated the procedure well. Explained to patient that larger catheter would be used next time to ensure sufficient drainage of bladder ..."
7/21/19 at 3:44 am, "Patient complaining of pressure to lower abdomen .... Patient straight-cathed with 14 Fr. 1300 ml of urine removed ..."
7/21/19 at 12:28 pm, "PVR 817 ml."
7/21/19 at 12:50 pm, " ...Removed 1000 cc ..."
7/21/19 at 4:34 pm, "PVR 395 ml."
7/21/19 at 6:07 pm, "PVR 651 ml."
7/21/19 at 7:36 pm, "UR 1000"

During an interview on the morning of 9/3/19, in the facility conference room, Staff #2, Chief Nursing Officer confirmed the in and out catheterizations were not being conducted as the physician had ordered.

Based on observations, interviews and record review the facility failed ensure nursing services in an organized manner when,

A.) The nurses did not follow physician's orders to perform an in and out catheter for a patient experiencing urinary retention placing the patient at risk of developing a urinary infection and pain from a distended bladder.

B.) The patient in room B110 was on isolation precautions, there was no sign on the door to inform staff and visitors of the type of protective equipment that needed to prevent spreading the infection to other patients.

Findings include:

A.) Review of Patient #4's medical records reflected a 48-year-old male admitted on 7/20/19. The PATIENT CARE ORDER x Continuous dated 7/20/19 reflected, "Timed voiding every 4 hours. If PVR (post void residual) greater than 350, proceed to I/O (in and out) cath ..."

Review of Patient #4's nursing's notes reflected the following,
7/20/19 at 11:40 am "PT FC FCD (Foley catheter discontinued) at this time."
7/20/ 19 at 11:59 am FUR (urinary residual) 400 ml."
7/20/19 at 3:40 am, "PVR (urinary residual) 810 ml"
7/20/19 at 4:57 am "Patient having ICP (in and out catheter), 1000 ml removed ..."
7/21/19 at 1:00 am, "Patient retaining urine. PVR revealed >900 ml. Procedure explained to patient. Patient straight-cathed for 8 Fr. 200 ml of urine removed. Patient tolerated the procedure well. Explained to patient that larger catheter would be used next time to ensure sufficient drainage of bladder ..."
7/21/19 at 3:44 am, "Patient complaining of pressure to lower abdomen .... Patient straight-cathed with 14 Fr. 1300 ml of urine removed ..."
7/21/19 at 12:28 pm, "PVR 817 ml."
7/21/19 at 12:50 pm, " ...Removed 1000 cc ..."
7/21/19 at 4:34 pm, "PVR 395 ml."
7/21/19 at 6:07 pm, "PVR 651 ml."
7/21/19 at 7:36 pm, "UR 1000"

During an interview on the morning of 9/3/19, in the facility conference room, Staff #2, Chief Nursing Officer confirmed the in and out catheterizations were not being conducted as the physician had ordered.

B.) Observations on the morning of 9/3/19, on the inpatient unit revealed Staff #8, CNA entering room B110, there was an isolation box, containing disposable gowns, masks, and gloves, hanging on the front of the patient door. Staff #8, CNA donned the gown and gloves and entered the room with the patient shared glucometer and a clear plastic box with multiple lancets, alcohol pads and the glucometer's calibration testing chemicals. The box was placed on a counter in the room. Staff #8. CNA left the room and did not wipe the glucometer or the box down.

During an interview on the morning of 9/3/19, Staff #2, CNO confirmed the finding and stated, "
She shouldn't have taken the box into an isolation room ... There should be an isolation sign on the wall."