Failure to Provide Appropriate Catheter Care
Penalty
Summary
The facility failed to provide appropriate treatments and services for the use of urinary catheters for three residents. Resident R3, who was admitted with a suprapubic catheter for a neurogenic bladder, was observed without a privacy-dignity bag on her catheter drainage bag, which was confirmed by a registered nurse. Resident R62, who uses a condom catheter due to neurogenic bladder and quadriplegia, was also observed without a privacy-dignity cover on his catheter bag, which was facing the door. This was confirmed by another registered nurse. Additionally, Resident R317, who was admitted with an indwelling catheter, had a physician's order that failed to specify the fluid amount needed for the catheter balloon. The resident's care plan also did not include the size of the catheter or the fluid amount required for the balloon. This oversight was confirmed by a registered nurse and the Director of Nursing, indicating a failure to ensure appropriate catheter-related treatments and services for these residents.
Plan Of Correction
Residents R3 and R62 had dignity bags applied at the time of survey. Resident R317's orders and care plan have been updated to include size and fluid amount needed for the catheter balloon. A whole house sweep has been conducted to ensure all catheters have dignity bag covers. All catheter orders and care plans will be reviewed to ensure they are complete. All licensed nurses will be educated by the DON or designee on physician orders for catheters, care plan requirements and resident dignity bags. The DON or designee will audit all catheter bags for dignity covers, orders for catheters to include size and fluid amount needed for the catheter balloon, and care plans to include the size of catheter or the amount of fluid needed for the catheter balloon. Audits will be completed weekly x 8 weeks. All results to be reviewed through QAPI for further recommendation.