Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling urinary catheters, as evidenced by two specific incidents. In the first case, a resident with a suprapubic urinary catheter experienced a change in condition when the catheter was not draining. Although the issue was identified and the resident was sent to the hospital and returned with a new catheter and antibiotics for a UTI, there was no documented evidence that licensed nurses continued to monitor or assess the resident's condition as required by facility policy. Both the LVN and DON confirmed that ongoing monitoring every shift for 72 hours following a change in condition was not performed, which was necessary to observe for complications or infection. In the second case, another resident with an indwelling urinary drainage catheter was observed with the catheter bag touching the floor. This was verified by an LVN, who acknowledged that the catheter bag should not be in contact with the floor. The resident was dependent on staff for activities of daily living and had the catheter in place for wound management. These lapses in catheter care and monitoring were directly observed and confirmed through staff interviews and medical record reviews.