Failure to Implement Catheter Orders and Document Care
Penalty
Summary
The facility failed to follow professional standards of practice for a resident with a suprapubic catheter. Specifically, the facility did not implement a urologist's order for daily sterile water flushes of the resident's suprapubic catheter on days when Renacidin was not used. Review of the resident's medical record and interviews with facility staff confirmed that the order for daily flushes was not entered into the electronic medical record, and nursing staff did not follow up to ensure the order was implemented. The resident had a history of urinary tract infection and obstructive and reflux uropathy, and was not their own responsible party. Additionally, the treatment nurse failed to document the care provided or an assessment after a complication was reported with the resident's suprapubic catheter. Progress notes indicated the resident had no urine output overnight and the treatment nurse was to flush the catheter, but there was no documentation of the procedure or assessment in the medical record. The treatment nurse later confirmed that the catheter was flushed and there was sediment present, but acknowledged that the procedure and outcome were not documented as required by facility policy.