Failure to Document and Provide Appropriate Catheter Care
Penalty
Summary
A resident with a history of benign prostatic hyperplasia and moderate cognitive impairment was observed with an indwelling urinary catheter in place after returning from the hospital. The resident's care plan only referenced the use of disposable briefs for urinary incontinence and did not mention the presence of a catheter. There was no physician order for the indwelling catheter in the medical record, nor was there documentation of catheter care or infection prevention interventions. The resident was unaware of the reason for the catheter and could not confirm if regular catheter care was provided. Staff interviews revealed uncertainty regarding the necessity of the catheter and a lack of documentation for catheter care and maintenance. The LPN stated that catheter care is generally performed every shift but acknowledged that there was no way to verify if this was done due to missing documentation. The DON confirmed that a physician order specifying the medical diagnosis, catheter size, and care interventions should have been present, and that the resident had not been assessed for catheter removal. These omissions resulted in a failure to provide appropriate care and services for a resident with an indwelling urinary catheter.