Failure to Provide Proper Catheter Care and Positioning
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, resulting in two deficiencies. For one resident with a history of falls, major depressive disorder, and type 2 diabetes mellitus, the facility did not provide indwelling catheter care or monitoring after the resident was readmitted from the hospital. The resident's physician order summary and treatment administration records showed no evidence of catheter care or monitoring after the readmission, and there were no physician orders for catheter care in the medical record. The assistant director of nursing confirmed that catheter care was not reinstated upon the resident's return from the hospital, despite facility policy requiring catheter care every shift and as needed. For another resident with urinary retention and type 2 diabetes mellitus, the facility failed to ensure proper positioning of the urinary catheter collection bag. During observation, the resident was seen sitting in a wheelchair with the catheter collection bag placed at the same level as the bladder, rather than below it as required. The registered nurse present confirmed that the collection bag should be positioned below the bladder to prevent backflow of urine, in accordance with facility policy and the resident's care plan. Both deficiencies were identified through interviews, record reviews, and direct observation. The facility's own policies and procedures, as well as the residents' care plans, specified the required catheter care and positioning, but these were not followed in the cases observed.