Failure to Monitor and Document Catheter Care and UTI Signs
Penalty
Summary
The facility failed to provide appropriate care and services for a resident with an indwelling catheter by not consistently monitoring for signs and symptoms of urinary tract infection (UTI) as required by the resident's care plan and facility policy. The resident, who was admitted with diagnoses including urine retention, hemiplegia, hemiparesis, and muscle weakness, had a care plan that specified monitoring for infection, urine characteristics, and discomfort, with documentation and prompt reporting to the physician if abnormalities were observed. Despite these directives, there were multiple instances where staff did not document or monitor the resident's urine for sediment, color changes, or pain, particularly during shifts when changes in the resident's condition were noted, such as the presence of white sediments, pinkish urine, and lower abdominal pain. Observations and interviews revealed that staff, including the DON, LVNs, and CNAs, acknowledged lapses in documentation and monitoring. The DON confirmed that there was no documentation of urine monitoring for several shifts when the resident had documented changes in urine appearance and discomfort. Staff interviews indicated that some did not check for sediments or document findings, and there was inconsistency in following the care plan interventions. The facility's policy required observation and documentation of urine characteristics and signs of UTI, but these procedures were not followed. Record reviews further showed that the required monitoring and documentation were missing during critical periods when the resident exhibited symptoms such as sediment in the catheter tubing, pinkish urine, and bladder pain. The DON stated that the facility lacked a clear policy on documenting changes of condition every shift for 72 hours, and staff were not consistently addressing or documenting the resident's change of condition. This failure to adhere to care plan interventions and facility policy resulted in a deficiency related to catheter care and UTI prevention.