Failure to Provide Comprehensive Catheter Care and Documentation
Penalty
Summary
The facility failed to provide comprehensive and resident-centered care for residents with indwelling urinary catheters, as evidenced by observations, interviews, and record reviews. One resident with a neurogenic bladder and an indwelling catheter was observed with the catheter bag improperly positioned on two occasions: once hanging above the bladder and once on the floor. Both instances were confirmed by nursing staff, and the facility's policy required catheter care to reduce infections and maintain proper gravity drainage. Another resident admitted with an indwelling catheter for urinary retention did not have a care plan, physician orders, or accurate assessment documentation regarding the catheter. The resident's Minimum Data Set (MDS) was incorrectly coded to indicate no catheter use, and staff interviews revealed a lack of awareness about the presence of the catheter. The Director of Nursing and Unit Manager confirmed the absence of necessary documentation and care planning, despite daily interactions with the resident. Facility policy required catheter care in accordance with clinical standards, which was not followed in this case.