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F0690
D

Failure to Assess and Support Self-Catheterization for Resident with Indwelling Catheter

Great Falls, Montana Survey Completed on 04-24-2025

Penalty

Fine: $65,800
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to address the discontinuation of an indwelling urinary catheter for a resident who was admitted with the device. The resident, who is paraplegic and has a history of neurogenic bladder, previously managed his condition through intermittent self-catheterization and expressed a desire to return to this method for greater independence. Upon admission, the resident communicated his preference and history to staff, and a physician order was placed to assess his cognitive and physical ability to resume self-catheterization. However, no such assessment was completed, and the resident continued to have an indwelling catheter in place. Multiple staff interviews revealed a lack of awareness regarding the referral and physician order for the necessary cognitive and self-catheterization assessment. Documentation confirmed that no therapy evaluation or cognitive assessment was performed, and the order was not present on the facility's communication board. Staff also indicated that there was confusion about how to order self-catheterization supplies, and no supplies were procured for the resident. The facility's own policies require timely assessment for catheter removal and appropriate services to restore continence or independence, but these were not followed in this case. The resident did not receive the ordered evaluation to determine his ability to self-catheterize, nor was he provided with the supplies or services needed to restore his previous level of independence. The failure to complete the assessment and provide appropriate care was confirmed through record review, staff interviews, and observation, demonstrating noncompliance with facility policy and professional standards of practice.

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