Failure to Document and Reassess Indwelling Catheter Use
Penalty
Summary
The facility failed to ensure appropriate clinical decision-making and documentation regarding the use of an indwelling urinary catheter for one resident. The resident, who was cognitively intact and independent with activities of daily living, had a history of urethral stricture and obstructive and reflux uropathy. Despite these diagnoses, the medical record did not contain documentation of the reason for the catheter's insertion, justification for its continued use, or evidence of periodic reassessment. There was also no documentation of any attempt to remove the catheter or a referral to urology for further management until recently, even though the resident had experienced multiple urinary tract infections (UTIs) associated with the catheter, including one that resulted in hospitalization for sepsis. Interviews with staff confirmed that no trial removal of the catheter had been attempted since the resident's admission, and the care plan only referenced long-term catheter use without further detail. The resident reported a history of frequent UTIs and expressed that the catheter was intended to remain until he could stand and care for himself, based on previous medical advice. The facility's electronic medical record lacked evidence of ongoing assessment or a clear plan for catheter management, and no relevant policy was provided upon request.