Failure to Document Catheter Care Leads to UTIs
Penalty
Summary
The facility failed to ensure that residents with indwelling Foley catheters received appropriate treatment and services to prevent urinary tract infections (UTIs). Specifically, for Resident 65, there was a lack of documentation indicating that catheter care was provided on multiple shifts from October through December 2024. This resident, diagnosed with urinary retention and using an indwelling Foley catheter, was found to have a UTI on October 25, 2024, with a urine culture indicating the presence of E. coli. The Nursing Home Administrator and Director of Nursing confirmed that catheter care should be provided and documented every shift. Similarly, Resident 72, who had diagnoses including benign prostatic hyperplasia and chronic kidney disease, also did not have documented catheter care on several shifts during the same period. This resident had physician orders for catheter checks every shift starting September 27, 2024. Despite this, there was no documentation of catheter care on numerous occasions, and the resident was treated with antibiotics for UTIs in October and December 2024. The Director of Nursing confirmed that catheter care should be completed and documented per facility protocol daily on every shift.
Plan Of Correction
1. R 65 has been evaluated and is currently experiencing no signs and symptoms of infection. R72 is currently being treated on antibiotic therapy and is showing no signs or symptoms of urinary tract infections. 2. Residents with indwelling catheters will be identified, and will be evaluated for signs and symptoms of urinary tract infections. In addition, documentation will be reviewed to validate catheter care has been completed. Physician will be notified for follow-up as needed. 3. Certified Nursing Assistants will be re-educated on completion of catheter care and proper documentation. Licensed Nurses will be re-educated on role and responsibility of oversight of completion of CNA documentation for each shift. 4. Director of Nursing or designee will conduct audits on at least 3 residents/per week with catheters to validate care documentation is complete. Results of audits will be forwarded to the facility Quality Assurance and Performance Improvement Committee x 12 weeks for review and recommendation.