Failure to Provide Appropriate Self-Catheterization Supplies and Oversight
Penalty
Summary
The facility failed to follow its self-catheterization policy and procedure for a resident who performed self-catheterization. The facility did not maintain adequate supplies, as only male self-catheterization kits were available, despite the resident being female and requesting the appropriate female kits. Both the Infection Preventionist and Materials Manager confirmed a lack of awareness regarding the need for gender-specific catheterization kits, and the central supply room did not stock female kits. The resident expressed frustration at not having the correct supplies and was observed using a male kit, which was not appropriate for her. Additionally, there was no physician order in place for the resident to perform self-catheterization, as confirmed by a review of the resident's medical orders with the Charge Nurse and Director of Nursing. Furthermore, there was no documented nursing assessment to ensure the resident was competent and able to perform self-catheterization safely, despite the facility's policy requiring such an assessment. The resident's plan of care noted self-catheterization, but no supporting assessment was found in the medical record.