Lack of Justification for Indwelling Catheter Use
Penalty
Summary
The facility failed to document the justification for the continued use of an indwelling urinary catheter for a resident who experienced a urinary tract infection. The resident, who was admitted with multiple diagnoses including chronic atrial fibrillation, morbid obesity, sepsis, and benign prostatic hyperplasia, was moderately cognitively impaired and dependent on staff for various activities. Despite having an indwelling urinary catheter, the resident's admission assessment did not identify its use, and the physician's order lacked a reason for the catheter or instructions for its care and maintenance. The resident's care plan did not include the presence of the indwelling catheter or interventions for infection prevention. A urine culture revealed a significant infection, and the resident received antibiotic treatment. The Acting Director of Nursing acknowledged the absence of documentation or evaluation justifying the catheter's continued use and was uncertain about the reason for its use. Additionally, there was no facility policy regarding the evaluation for the justification of indwelling urinary catheter use.