Failure to Provide Indwelling Catheter Care per Policy
Penalty
Summary
The facility failed to provide indwelling catheter care as required by its own policy for a resident with significant medical needs, including chronic respiratory failure, neurogenic bladder, and paraplegia. The resident was dependent on staff for all activities of daily living and had an indwelling catheter. The care plan specified that catheter care should be performed every shift. Documentation showed that catheter care was completed every shift prior to the resident's discharge to the hospital, but after the resident's readmission, there was no documentation of catheter care being performed for an extended period. Interviews with the resident revealed that catheter care was often not performed during the night shift, and the resident reported going several days without receiving this care. The President of Clinical Services confirmed that the medical record lacked documentation of catheter care following the resident's readmission, which was not in accordance with facility policy. Review of the facility's catheter care policy confirmed that care was to be provided every shift and as needed, but this standard was not met for the resident in question.