Failure to Provide Appropriate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident admitted with an indwelling urinary catheter. Despite the resident having a complex medical history including morbid obesity, type 2 diabetes with chronic kidney disease, diabetic foot ulcers, congestive heart failure, generalized edema, dependence on renal dialysis, and a malignant neoplasm, there was no physician order for the indwelling urinary catheter in the resident's active orders. Observations revealed the resident had a urinary catheter draining cloudy urine, and interviews confirmed the resident was admitted with the catheter. However, the Minimum Data Set (MDS) assessment did not indicate the presence of an indwelling catheter, and the care plan only addressed a urinary tract infection (UTI) without any interventions related to catheter care. Further review of the Medication Administration Record (MAR) showed no documentation of catheter care or monitoring of urine characteristics such as color, amount, or consistency. Staff interviews confirmed that catheter care was performed and urine was emptied, but there was no designated place for documentation. The Director of Nursing and other staff acknowledged the lack of a physician order, absence of monitoring and documentation, and missing care plan interventions for the indwelling catheter, all of which are inconsistent with professional standards and the facility's own catheter care policy.