Failure to Provide and Document Required Catheter Care
Penalty
Summary
The facility failed to implement its catheter care policy and procedure for a resident with a suprapubic catheter. The resident, who was admitted with diagnoses including hydroureter, chronic kidney disease, and obstructive reflux uropathy, had a physician's order for catheter care to be performed with soap and water every shift and as needed. Review of the Treatment Administration Record (TAR) for the month of March revealed multiple shifts where catheter care was not documented as completed, specifically on several day and evening shifts throughout the month. During interviews and record reviews, the Director of Nursing (DON) confirmed that staff are required to perform and document catheter care every shift, in accordance with both the physician's order and the facility's policy. The facility's policy, which aims to improve hygiene and reduce infection, was not followed as evidenced by the missing documentation and unperformed catheter care on the identified dates.