Failure to Provide Appropriate Catheter Care and Documentation
Penalty
Summary
Staff failed to provide appropriate catheter care for a resident with an indwelling urinary catheter. The resident, who was severely impaired in decision-making and had multiple diagnoses including pneumonia, viral hepatitis, wound infection, cerebrovascular accident, seizure disorder, traumatic brain injury, and respiratory failure, had physician orders for catheter care and output monitoring. However, the orders did not include a diagnosis for the catheter. The resident's care plan also lacked specific instructions for the management, assessment, handling, and maintenance of the indwelling catheter, as well as what to monitor while the catheter was in place. During observations, the resident was seen sitting in a wheelchair with the catheter bag hanging under the chair and the tubing touching the floor on multiple occasions. The DON confirmed that the care plan should address the indwelling catheter and that catheter tubing should be kept off the floor and coiled inside the privacy bag. Facility policy required documentation of the reason for catheter use and specified that catheter tubing and drainage bags should not touch the floor, but these procedures were not followed for this resident.