Failure to Document and Respond to Change in Condition for Catheterized Resident
Penalty
Summary
A deficiency occurred when a resident with an indwelling urinary catheter did not receive appropriate care and services as required by facility policy and physician orders. The resident, who had moderate cognitive impairment, was observed on multiple occasions with cloudy urine and sediments in the catheter tubing. Despite these findings, which were recognized by nursing staff as a change in condition and potential sign of infection, there was no documentation of a change of condition (COC) assessment, progress notes, or care plan in the resident's electronic health record (EHR) for several days. Interviews with licensed nursing staff confirmed that the facility's policy required immediate reporting and documentation of unusual findings such as cloudy urine with sediments. However, staff acknowledged that no COC documentation, progress notes, or care plan had been completed for the resident's condition during the relevant period. One nurse stated that the change was reported to other staff, but those staff members did not follow up with the required documentation or care planning. The administrator was informed and acknowledged these findings.