Failure to Provide Required Staff Assistance and Education for Indwelling Urinary Catheter Care
Penalty
Summary
A deficiency was identified regarding the care and management of an indwelling urinary catheter for one resident with diagnoses of obstructive and reflux uropathy and a history of urinary tract infections. The resident's care plan specified a need for maximal staff assistance with catheter management, including emptying and changing urinary drainage bags, monitoring urine output and color, and providing new drainage bags. However, observations over several days revealed that the resident was independently managing their catheter care, including switching between leg and overnight drainage bags, emptying and cleaning the bags, and storing the overnight bag in a pink basin with uncapped tubing next to the bathroom sink. There was no evidence that staff provided the required assistance or monitored the resident’s catheter care as outlined in the care plan. Interviews with certified nurse aides and nursing staff confirmed that the resident was allowed to manage their own catheter care without staff oversight or documented education. The aides believed the resident was independent in this task and did not monitor the process, relying on the resident to self-report urine output for documentation. Both aides and nurses were unaware that the care plan required maximal assistance, and there was no documentation that the resident had been trained or assessed for competency in managing their catheter care independently. The facility’s policy required regular monitoring, education, and documentation for residents with indwelling urinary catheters, including ensuring a sterile closed system and providing education with documentation of understanding and follow-up. Despite these requirements, there was no documentation that the resident received education or was assessed for independent catheter care. The lack of staff involvement and oversight, as well as the absence of documented education, directly led to the deficiency in providing necessary services and treatment for the resident’s indwelling urinary catheter.