Failure to Provide and Document Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide proper care and services for a resident with an indwelling urinary catheter. Specifically, there was no physician's order for the catheter upon the resident's readmission from an acute care hospital, and the required catheter care and monitoring were not documented in the resident's medical records. The resident's care plan called for catheter care every shift, perineal care during bowel elimination, and monitoring for signs and symptoms of infection, but these interventions were not followed. The Treatment Administration Record did not reflect any catheter care or monitoring, and the licensed nursing staff confirmed that these actions were not performed or documented. The resident had a history of epilepsy, Parkinson's disease, urinary retention, and a prior history of urinary tract infection, making proper catheter care and monitoring especially important. Despite these risk factors, the facility did not assess or monitor the resident for urinary tract infection or other catheter-associated complications as required by both the care plan and facility policy. The Director of Nursing acknowledged that the necessary assessments and documentation were not completed for the resident.