Deficiency in Urinary Catheter Documentation and Care Planning
Penalty
Summary
The facility failed to ensure that physician orders for urinary catheters included necessary details such as the size of the catheter and the amount of fluid required for balloon inflation for two residents. Resident R66, who has a history of thyroid disorder, Parkinson's disease, and coronary artery disease, had a foley catheter inserted without documentation of the catheter size in the physician's orders. Observations confirmed the presence of the catheter, but the necessary details were missing from the clinical records. A registered nurse confirmed this oversight during an interview. Similarly, Resident R118, diagnosed with congestive heart failure, atrial fibrillation, and chronic obstructive pulmonary disease, had a foley catheter order that lacked information on the catheter size and balloon inflation fluid. Additionally, the baseline care plan for Resident R118 did not include care instructions for the foley catheter. This deficiency was also confirmed by a registered nurse during an interview, highlighting the facility's failure to provide comprehensive documentation and care planning for residents with urinary catheters.
Plan Of Correction
R66 and R118 have been discharged. All current residents with catheters have been reviewed and appropriate care plans and orders have been entered to include size and amount of fluid needed. All RNs and LPNs will be educated by the Director of Nursing and/or designee that when a catheter is ordered or present, the MD order must state the appropriate size and fluid needed. There must also be care plans in place for all residents with catheters. The Director of Nursing and/or designee will review all residents with catheters present weekly for one month and monthly thereafter or until substantial compliance is achieved to ensure the MD order notes the appropriate size and fluid needed and that there is a care plan in place. Results will be reviewed at the Quarterly QAA meeting.