Failure to Monitor and Provide Care for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide appropriate care and monitoring for a resident with an indwelling urinary catheter. Specifically, staff did not monitor or document the resident's intake and output, assess urinary catheter drainage each shift, or perform catheter care every shift as required by facility policy and the resident's care plan. The resident's medical record lacked evidence of these essential assessments and interventions from the date of admission through the review period. Additionally, the facility did not complete a physician-ordered voiding trial or arrange for a follow-up with urology as directed in the hospital discharge orders. During observation, the resident was found in bed with an indwelling urinary catheter that had brown dried debris at the insertion site, and the resident reported that staff did not clean the catheter tubing daily. The Regional Nurse Consultant confirmed that the voiding trial and urology follow-up were not completed, and that monitoring of intake and output, urinary drainage, and catheter care every shift did not occur. These findings indicate a failure to follow physician orders, facility policy, and the resident's care plan regarding catheter management and infection prevention.