Failure to Assess, Monitor, and Document Catheter Care Leading to Adverse Outcomes
Penalty
Summary
The facility failed to accurately assess, monitor, and document catheter care for three residents who had indwelling urinary catheters, resulting in significant negative outcomes. In one case, a resident with a history of diabetes, neurogenic bladder, and recurrent UTIs experienced severe abdominal pain, distention, and lack of urine output. Despite repeated complaints from the resident and their family, nursing staff did not promptly assess or document the resident's condition, failed to monitor urine output, and did not document catheter care or replacement. The resident was not sent to the hospital until several hours after symptoms began, and upon arrival, was found to be in septic shock due to a UTI, ultimately leading to death. There was no documented order for the catheter, no record of medical necessity, and no documentation of urology consultations or follow-up on recommendations. For two additional residents with catheters, the facility did not document urine output or catheter care as required. One resident had a foley catheter with orders for daily care and monitoring, but there was no documentation of urine output or evidence that straight catheterization was attempted as ordered. Progress notes indicated abnormal urine characteristics, but lab orders were not consistently placed or followed up. The other resident, who was non-verbal and had a history of UTI and urinary retention, had inconsistent documentation regarding catheter care and monitoring. The care plan did not address catheter care, and the electronic record lacked specific documentation of catheter care or urine output, despite orders and care plan interventions indicating these should be monitored. Interviews with facility staff, including the DON and nurse practitioners, revealed a lack of clarity and consistency regarding protocols for catheter care, documentation, and monitoring. Staff were unable to explain why required documentation was missing or why care plan interventions were not followed. The facility's own policy required monitoring and documentation of catheter care and urine output, but these practices were not consistently implemented or recorded for the residents reviewed.