Failure to Provide Appropriate Catheter Care and Privacy for Residents
Penalty
Summary
The facility failed to provide appropriate treatments and services for residents with indwelling urinary catheters, as required by both federal and state regulations. Specifically, two residents with complex medical histories, including chronic kidney disease, urinary tract infections, and obstructive and reflux uropathy, did not receive care in accordance with facility policies. Documentation was lacking regarding catheter removal procedures, including assessment data, resident tolerance, and post-removal monitoring. For one resident, after a foley catheter was discontinued, there was no evidence that staff offered frequent toileting attempts or documented assistance with continence or incontinence, despite orders for bladder scans and fluid intake. This resident ultimately required re-insertion of the catheter due to incomplete bladder emptying. Observations revealed that both residents with indwelling catheters did not have their catheter drainage bags covered with dignity bags for privacy, as required by facility policy. On multiple occasions, the catheter bags were visible and not shielded from view, either hanging on a wheelchair, walker, or bed frame. Staff interviews confirmed that the required privacy measures were not consistently implemented. The Director of Nursing acknowledged that the facility did not ensure appropriate treatment and services for the two residents with indwelling urinary catheters. The deficiencies were also found to be in violation of several Pennsylvania state codes related to management, resident care policies, and nursing services.
Plan Of Correction
R331's MD was notified of concern having orders for output, measuring and recording of urinary output for resident's catheter management. R51 was provided with a Foley privacy bag. All residents with Foley catheters were audited for privacy bags and Foley management orders reviewed to ensure output documentation within a 24-hour period is inclusive. DON or designee will educate nurses on proper Foley catheter management including documentation of output for all residents with a Foley catheter and proper placement of catheters in a dignity bag. Facility IP or designee will audit all Foley catheter residents for appropriate chart documentation and privacy bags 1 time a week for 4 weeks, then monthly for 2 months. Results will be reviewed at QAPI and revised as needed.