Lack of Documented Diagnosis for Indwelling Catheter
Penalty
Fine: $31,425
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
Surveyors found that the facility failed to document a diagnosis or indication for the use of an indwelling catheter for one resident. During observations, a resident was noted to have an indwelling catheter in place. Review of the resident's physician order sheet showed an order for the catheter, specifying the size and balloon volume, but the section for diagnosis or reason for the catheter was left blank. The Director of Nursing confirmed that a diagnosis should be documented on the physician order to indicate the reason for the indwelling catheter. The facility's own policy also requires that physician orders specify the diagnosis or indication for use, but this was not followed in this case.