Lack of Documented Foley Catheter Care and Urine Monitoring
Penalty
Summary
A deficiency was identified when a resident with a history of neuromuscular bladder dysfunction and previous urinary tract infections was admitted with a Foley catheter. Review of the resident's admission record and Minimum Data Set indicated the resident required substantial assistance with toileting hygiene. However, there was no documentation in the medical record of Foley catheter care being provided or of monitoring the urine for signs and symptoms of infection. During interviews, the treatment nurse confirmed the absence of documentation regarding Foley care and urine monitoring. The Director of Nursing also stated that residents with Foley catheters should receive catheter care and have their urine assessed every shift for infection indicators. Facility policies reviewed indicated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene, but there was no evidence these services were documented or provided in this case.