Incomplete Documentation of Catheter Care and Monitoring
Penalty
Summary
The facility failed to maintain a complete medical record for one resident reviewed for closed records. Specifically, there was inconsistent documentation regarding the monitoring and care of an indwelling urinary catheter and the checking of a Quinton catheter, which is used for hemodialysis access. The resident in question had diagnoses including end stage renal disease, dependence on renal dialysis, obstructive and reflux uropathy, and required both a Foley catheter and a Quinton catheter. Facility documentation required catheter care and monitoring every shift, with specific instructions to check for signs of infection, bleeding, and other complications, and to document these checks. Upon review of the resident's Treatment Administration Record (TAR) for April, it was found that there was no nursing documentation for the required catheter care and Quinton catheter checks on two PM shifts. Interviews with an LVN and the ADON confirmed the missing documentation, with both acknowledging that the care may have been provided but was not recorded. This lack of documentation resulted in the medical record being incomplete, as required by federal regulations and facility policy.