Failure to Provide Comprehensive Catheter Care and Documentation
Penalty
Summary
The facility failed to provide comprehensive and individualized treatment and maintenance plans for residents with indwelling urinary catheters, as evidenced by the care of two residents. For one resident, medical records showed an indwelling catheter was reinserted following a urology appointment, but there were no corresponding physician orders for catheter care or documentation of catheter care in the Treatment Administration Record (TAR) for several months. Observations revealed the resident had a catheter in place with visible urine and sediment, and the insertion site was slightly red. Staff interviews confirmed the absence of catheter care orders, lack of daily documentation of urine output, and that the catheter was not properly secured. Nursing staff acknowledged that catheter care orders and documentation should have been present and that the catheter should not have been clamped after placement. For the second resident, medical records indicated the presence of a suprapubic catheter and multiple diagnoses related to urinary retention and bladder disorders. However, there were no physician orders for catheter care, and the resident's care plan did not address catheter care. The last documented catheter care was over two months prior to the survey, and the TAR for the relevant period did not include any catheter care treatments. Staff interviews confirmed the absence of catheter care orders, care plan interventions, and recent documentation of catheter care. A review of the facility's catheter care policy revealed that catheter care should be performed every shift and as needed, with specific instructions for maintaining privacy, changing bags, and ensuring proper drainage. The facility did not follow its own policy, as evidenced by the lack of orders, documentation, and care planning for residents with indwelling catheters.