Lack of Documentation for Monthly Foley Catheter Change
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of urinary retention and an indwelling Foley catheter did not have documented evidence that their catheter was changed according to physician's orders. The physician's orders and the resident's care plan both specified that the Foley catheter was to be changed every month by urology. However, a review of the electronic medical record for March 2025 revealed no documentation that the catheter was changed or replaced during that month. The facility was unable to provide any evidence to confirm that the catheter change occurred as ordered. The Director of Nursing confirmed the lack of documentation and was unable to dispute the findings. This deficiency was based on interview and record review, focusing on the facility's failure to ensure appropriate catheter care and adherence to physician's orders for catheter changes for the resident in question.