Failure to Document Foley Catheter Removal
Penalty
Summary
The facility failed to document the removal of a foley catheter for a resident, as required by its own policies and procedures. The resident, who had a history of pressure ulcers and cellulitis and was cognitively intact but dependent on staff for activities of daily living, requested removal of the foley catheter. A physician's order was obtained for the removal, and the treatment nurse performed the procedure. However, there was no documentation in the resident's medical record indicating when the catheter was removed, details of the removal process, or how the resident tolerated the procedure. During interviews, the treatment nurse confirmed that she removed the catheter but did not document the event, believing it was unnecessary since nothing unusual occurred. The facility's policies require that all treatments and procedures, including the date, time, assessment data, and resident response, be documented in the medical record. The lack of documentation resulted in incomplete communication among staff regarding the resident's care.