Failure to Monitor and Document Indwelling Catheter Function
Penalty
Summary
A deficiency occurred when the facility failed to properly monitor and document the use and function of an indwelling urinary catheter for a resident with multiple diagnoses, including neurogenic bladder and a history of urinary tract infection. The resident's care plan and physician orders required licensed nurses to check catheter functionality and monitor for complications every shift, including observing for signs of infection, catheter occlusion, and changes in urine output or appearance. Despite these requirements, observations over several days revealed the resident's catheter drainage bag contained sediment, dark cloudy urine, and later, a scant amount of dark blood-tinged urine. The resident also exhibited increased anxiety, a distended abdomen, and an increased respiratory rate, but there was no documentation of these findings or any action taken to address the catheter's function during this period. The resident reported feeling the urge to urinate and abdominal discomfort, which had persisted since the previous evening. Staff interviews confirmed that the LPN was unaware of the abnormal urine output and had not notified the provider until prompted. Upon assessment by the provider, a bladder scan revealed significant urine retention, leading to the immediate replacement of the non-functioning catheter, which resulted in prompt relief of the resident's symptoms. The lack of timely assessment, documentation, and intervention regarding the resident's catheter and urinary output constituted a failure to provide appropriate catheter care as required by facility policy and professional standards.