Deficient Catheter Care and Urinalysis Testing
Penalty
Summary
The facility failed to adhere to its policies and procedures for catheter care and urinalysis testing for three residents. Resident #2 was readmitted with multiple diagnoses, including urinary retention and a history of urinary tract infection (UTI). Despite a physician's order for urinalysis and culture due to blood-tinged and cloudy urine, there were no urinalysis results in the medical record. The facility did not implement a task for documenting catheter care, and the Administrator confirmed that catheter care documentation was not performed. Resident #4, who had a Foley catheter and was dependent on assistance for mobility and toileting, expressed concerns about staff not emptying her catheter bag frequently enough. Documentation showed the catheter was emptied only once a day on several occasions, and not at all on one day, despite the facility's policy to empty the drainage bag every shift. An observation confirmed the resident's catheter bag was partially filled with urine and sediment. Resident #5, also with a Foley catheter, had documentation indicating the catheter was emptied only once a day on certain days and not at all on others. The facility's policy required emptying the catheter bag every shift, but this was not consistently documented or performed. The Administrator acknowledged issues with laboratory services and a lack of follow-up on urinalysis testing, contributing to the deficiency in care for these residents.
Plan Of Correction
1. Resident #2 no longer resides in the facility. Resident #4 is a long-term resident of the facility; the care plan was reviewed and was deemed appropriate. 2. Like residents were identified as those with Foley catheters and are at risk for developing urinary tract infections. Like residents' medical records were reviewed between 3/22/25 through 3/25/25 to ensure their plan of care includes interventions for the prevention of a urinary tract infection. 3. The policy regarding indwelling catheter care and maintenance was reviewed and deemed appropriate. Licensed nurses were educated by the DON/designee on appropriate processes for initiating timely interventions upon admission and with any change of condition between 3/13/25 and 3/21/25. 4. The QAPI committee has directed the DON/designee to perform random weekly audits to ensure interventions for catheter maintenance are initiated timely upon admission. The Administrator is responsible for ensuring that substantial compliance is attained through the Plan of Correction and is maintained thereafter. The results will be provided to the QAPI Committee for further follow-up and review. Date of compliance 3/27/2025.