Failure to Provide and Document Physician-Ordered Catheter Care
Penalty
Summary
The facility failed to ensure that physician-ordered catheter care was provided and properly documented for three residents with indwelling or suprapubic catheters. For one resident with a suprapubic catheter and diagnoses including lymphedema, chronic kidney disease, and obstructive uropathy, there were multiple instances where the Treatment Administration Record (TAR) showed no documentation of required catheter site cleaning and dressing changes, as ordered by the physician. The resident reported that staff sometimes went several days without changing the dressing, and facility staff confirmed the lack of documentation for these treatments. Another resident with an indwelling urinary catheter and diagnoses of type II diabetes mellitus and obstructive and reflux uropathy also had missing documentation of catheter care on several shifts, as confirmed by nursing staff. A third resident with a suprapubic catheter and diagnoses including diabetes mellitus type II, peripheral vascular disease, and congestive heart failure had no documentation of required catheter care and application of prescribed Mupirocin ointment on multiple occasions. Facility policy required catheter care every shift, but records and staff interviews confirmed that care was not consistently provided or documented as ordered.