Failure to Implement and Document UTI Monitoring for Catheterized Resident
Penalty
Summary
The facility failed to implement a care plan intervention to monitor for signs and symptoms of urinary tract infection (UTI) for a resident with an indwelling foley catheter. The resident had diagnoses including obstructive uropathy, malignant neoplasm of the bladder, and generalized muscle weakness, and required moderate assistance with daily activities. The care plan specifically included monitoring for UTI symptoms such as chills, fever, sediment build-up, blood clots, bladder distention, and changes in urine output, with the goal of preventing UTI development. Despite these interventions being outlined in the care plan, there was no documentation in the Treatment Administration Record or clinical nursing notes indicating that the resident was monitored for UTI symptoms. During observation, a nurse identified the presence of yellow/white sediments in the resident's catheter tubing, which is a sign of UTI, but confirmed that monitoring and documentation had not occurred. The Director of Nursing also verified the absence of required documentation and emphasized the importance of following care plan interventions to detect and treat UTIs early.