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F0690
D

Failure to Assess Necessity of Indwelling Catheter

Wyndmoor, Pennsylvania Survey Completed on 01-10-2025

Penalty

Fine: $11,550
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident admitted with an indwelling urinary catheter was properly assessed for the necessity of the catheter's continued use. The resident, who was admitted following an acute hospitalization for an infection post-spinal surgery, had a diagnosis of sepsis and multiple pressure injuries, including an unstageable pressure ulcer on the sacrum. Despite the facility's policy stating that indwelling catheters should be used sparingly and only for appropriate indications, there was no documented rationale or clinical justification for the catheter's continued use in the resident's clinical record. The resident's care plan included goals to remain free from catheter-related trauma and to monitor for pain and discomfort. However, the Director of Nursing clarified that the catheter was used to keep the resident's wound dry due to incontinence, yet there was no documented evidence supporting this need. Additionally, a wound vac was ordered to promote wound healing, further questioning the necessity of the catheter. The lack of documentation and assessment for the catheter's necessity constitutes a deficiency in the facility's care for the resident.

Plan Of Correction

1. Resident R64 was assessed for the removal of the catheter. 2. Residents who have catheter will be assessed for removal of the catheter. 3. Staff will be educated on the components of this regulation with an emphasis on proper assessment and management of bowel/bladder incontinence, catheters, and UTIs. 4. Residents with a catheter will be audited for a removal of catheter 1x week for 1 month, 2x a month for one month and then 1x a month for 1 month. 5. The findings of these quality monitoring's to be reported to the Quality Assurance/Performance Improvement Committee monthly x6 months.

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