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 observations and record reviews. For one resident with severe cognitive impairment and neuromuscular bladder dysfunction, staff were observed transporting the resident in a wheelchair while the catheter drainage bag, attached beneath the chair, dragged on the floor. Staff interviews confirmed that the drainage bag should not have been in contact with the floor, but noted challenges in keeping the bags elevated due to the design of some chairs. Another resident, who was cognitively intact and required assistance with daily care, had a physician's order for the indwelling catheter to be changed every 30 days. However, there was no documented evidence that the catheter change was completed as ordered. Additionally, a third resident with obstructive uropathy was observed with catheter tubing in direct contact with the floor, and the drainage bag partially exposed and not fully covered for dignity. Staff interviews confirmed awareness of the requirement to keep catheter equipment off the floor and properly covered, but these standards were not maintained during the observed incidents.