Failure to Provide and Document Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide adequate catheter care for two residents, resulting in deficiencies related to catheter site hygiene and documentation. One resident with a suprapubic catheter reported that the site had not been cleaned or the dressing changed for three days, and this lack of care persisted even after the concern was voiced to staff. The resident, who was dependent for all activities of daily living due to paraplegia and had multiple comorbidities including neurogenic bladder and chronic kidney disease, stated that catheter care had not been performed correctly since a nurse who previously provided her care resigned. Staff interviews confirmed that the catheter site had not been cleaned or the dressing changed as required during the previous shift, and that CNAs were only responsible for emptying the catheter bag, not for site care. Another resident with an indwelling urinary catheter reported that catheter care was not consistently performed every shift as ordered. Review of the treatment administration record revealed multiple shifts where catheter care was not documented as completed. This resident was cognitively intact and had an order for catheter care every shift with soap and water. Laboratory results indicated that the resident developed a urinary tract infection, and an antibiotic was subsequently ordered. Facility policy required catheter care to be performed every shift and documented accordingly, including assessment data and any problems noted. The policy also outlined the importance of maintaining aseptic technique, securing the catheter, and monitoring for signs of infection. The failure to provide and document catheter care as ordered and per policy led to the identified deficiencies for both residents.