Failure to Ensure Ongoing Medical Justification and Assessment for Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter had ongoing medical justification for its use and did not attempt a trial removal as recommended. The resident, who had moderate cognitive impairment and required assistance with toileting and bathing, was admitted with a catheter in place. Although the resident's diagnoses included several conditions that could potentially justify catheter use, the electronic medical record did not document the duration of urinary retention, any attempts to manage the condition without a catheter, or clear medical justification for continued catheterization. There was also no evidence of post void residual measurements to assess the extent of urine retention. Additionally, a urology note indicated a plan for a suprapubic catheter placement, but the record lacked follow-up on this order. Interviews with the resident and nursing staff revealed that the catheter had been in place since admission, primarily to prevent urine leakage during travel, and that no attempts had been made to remove it or reassess the need for ongoing catheterization. The facility's policy addressed catheter care procedures but did not address the need for ongoing assessment or justification for continued use.