Failure to Ensure Proper Catheter Management and Documentation
Penalty
Summary
Staff failed to ensure proper management of an indwelling urinary catheter for a resident who was always incontinent of bowel and bladder and had a history of type two diabetes mellitus, heart disease, and head injury. The resident was observed multiple times with the urinary drainage bag attached to the second bar of a rolling walker at waist level, rather than positioned below the level of the bladder as required to prevent backflow and potential contamination. During one observation, urine with sediment was seen backing up into the tubing near the resident's bladder area. A Certified Nursing Assistant (CNA) stated that the resident preferred the bag on the walker for easier bathroom access and was unsure how to position the bag lower to promote proper drainage. Additionally, a review of the resident's medical record revealed there was no physician order or documented justification for the use of the indwelling catheter, despite facility policy requiring such documentation. A Licensed Practical Nurse (LPN) confirmed the absence of an order for the catheter. The facility's policy also required timely assessment for catheter use and criteria for discontinuation, which was not documented in this case. The administrator acknowledged the expectation for a medical diagnosis and adherence to catheter management policies for all residents with indwelling catheters.