Failure to Ensure Valid Medical Justification and Assessment for Indwelling Catheter Use
Penalty
Summary
Facility staff failed to ensure that an indwelling urinary catheter for one resident had a valid medical justification or a plan for discontinuation, as required by facility policy. The resident, who was admitted with a diagnosis of renal insufficiency but without obstructive uropathy or neurogenic bladder, had a catheter placed during a prior hospitalization. Upon admission, the resident's Minimum Data Set (MDS) indicated the presence of the catheter, and a later MDS showed a new diagnosis of obstructive uropathy. However, there was no documentation supporting a history of untreatable urinary blockage or inability to void prior to hospitalization. Staff initiated a voiding trial and discontinued the catheter per provider order, but failed to document the number of times the resident urinated, the volume of urine output, or any post-void residuals. The catheter was reinserted after staff noted urinary retention, but there was no evidence that a urology consult was considered to confirm the need for continued catheter use. Additionally, there was no documentation of interventions to address the potential decline in bladder function due to prolonged catheter use. Staff interviews confirmed that required assessments and policy protocols were not followed.