Failure to Document Intermittent Catheterization Procedure
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who required intermittent catheterization. Specifically, although a physician's order was in place for a straight catheter to collect a urine sample, the procedure was performed by an LVN but not documented in the resident's medical record. Both the LVN and the Director of Nursing confirmed that the procedure and the resident's response should have been recorded, as this information is essential for communication regarding the resident's care and safety. The resident involved had diagnoses including anxiety disorder, urinary tract infection, and diabetes mellitus, and was assessed as having intact cognitive function and requiring maximal assistance for toileting hygiene and lower body dressing. Facility policy required detailed documentation of catheterization procedures, including date, time, staff involved, urine characteristics, resident response, and any complications. The lack of documentation was contrary to both facility policy and accepted professional standards.