Failure to Provide Timely and Appropriate Catheter Care
Penalty
Summary
A deficiency occurred when a resident with a history of urinary retention and benign prostatic hyperplasia, who was cognitively intact and dependent on an indwelling Foley catheter, did not receive appropriate catheter care. The resident's care plan included monitoring for signs and symptoms of catheter complications and reporting them to the medical doctor, as well as interventions to evaluate for urinary complaints and urine characteristics. Physician orders specified that the Foley catheter should be changed if leaking, occluded, dislodged, or excessively sedimented, and to irrigate if clogged. Despite these orders and care plan interventions, the resident experienced a nonfunctioning and leaking Foley catheter, with urine leaking around the urethra and onto bedding, and no urine output for several hours. Documentation showed that the issue was identified by nursing staff, who attempted to flush the catheter without success, but the catheter was not changed and the physician was not notified in a timely manner. The resident reported the problem and discomfort, and staff interviews confirmed awareness of the malfunctioning catheter and the need for physician notification and catheter change. The facility's policy required physician notification and discontinuation of nonfunctioning catheters, but these steps were not followed promptly, resulting in a failure to provide appropriate catheter care as required.