Failure to Maintain Proper Catheter Care and Documentation
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, as evidenced by multiple instances where catheter drainage bags and tubing were observed in direct contact with the floor. For three residents with indwelling catheters, observations revealed that either the catheter tubing or drainage bag was lying on the floor while the resident was in a wheelchair or bed. Staff interviews confirmed that catheter equipment should not be in contact with the floor, and the facility's policy required drainage bags to be positioned below the bladder and off the floor. In one case, a nurse aide acknowledged that the drainage bag often slid off the wheelchair, resulting in contact with the floor. Additionally, the facility failed to consistently document urinary output for a resident with a physician's order and care plan directive to measure and record output every shift. Review of clinical records showed multiple dates and shifts where no documentation of urinary output was present, contrary to facility policy and physician orders. The DON confirmed the lack of documentation for the specified dates and shifts.