Failure to Monitor and Document Catheter Assessments for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to ensure that residents with indwelling urinary catheters were properly assessed and monitored for the presence of sediments, hematuria, and cloudy urine as required by physician orders and the residents' care plans. For two residents with significant cognitive impairment and dependence on staff for activities of daily living, there was no documentation that licensed staff assessed or monitored the catheter tubing and drainage bags for signs of infection or complications every shift, as ordered. One resident with a history of obstructive uropathy, benign prostatic hyperplasia, and prior urinary tract infection had a physician order to monitor the Foley catheter tubing and bag for sediments, hematuria, and cloudy urine every shift. However, review of the medical record and interviews with nursing staff confirmed that there was no documentation of these assessments being performed. The care plan for this resident also required staff to observe for signs and symptoms of UTI, but this was not carried out as documented. Another resident with chronic kidney disease and BPH had a Foley catheter in place and was similarly dependent on staff. During observation, white sediments were noted in the catheter tubing, which staff acknowledged could indicate infection. Despite this, there was no evidence that regular monitoring and assessment were documented as required. Facility policy and procedure required observation for complications and reporting of findings, but these were not followed for the residents in question.