Failure to Assess and Document Indwelling Catheter Use and Care
Penalty
Summary
A deficiency occurred when a resident admitted with an indwelling urinary catheter was not properly assessed for catheter removal, did not receive a follow-up with a urologist as ordered, and lacked physician orders for catheter care. The resident, who had a history of brain cancer, dementia, recent hospitalization, and multiple other medical conditions, was observed on several occasions with a Foley catheter in place. Despite the presence of the catheter, there were no corresponding physician orders for its use or care documented in the resident's medical record since admission. Review of the resident's hospital discharge summary did not reveal a diagnosis of urinary retention or any urologist consultation, even though the facility's records listed urinary retention as a diagnosis. The Minimum Data Set (MDS) assessment and care area documentation did not provide a clinical rationale for the ongoing use of the indwelling catheter, and the section supporting the use of the Foley catheter was left blank. Additionally, a physician's note recommended a urology follow-up, but there was no evidence that this follow-up occurred. Interviews with facility staff, including an LPN and the DON, confirmed that there were no physician orders for the catheter and that staff were unaware of this omission. The facility's own policy requires that indwelling catheters be used only when clinically necessary, with appropriate documentation, physician orders, and ongoing assessment, none of which were present in this case.