Inaccurate Assessment of Indwelling Catheter Status
Penalty
Summary
The facility failed to ensure the accuracy of resident assessments regarding indwelling catheters for one resident. During an observation, the resident was found in bed with a bedside commode and no indwelling catheter present. The resident's face sheet indicated diagnoses of dementia and peripheral vascular disease, and a quarterly assessment documented the presence of an indwelling catheter. However, a review of the medical record for the assessment period revealed no physician order for a catheter, and the resident stated they did not have one and could not recall ever having one. The minimum data set coordinator later confirmed that the resident did not have an indwelling catheter during the assessment period and that the assessment had been coded in error.