Failure to Provide Ordered Catheter Care and Inaccurate Documentation
Penalty
Summary
The facility failed to provide catheter care as ordered for one resident with a suprapubic catheter. A physician's order required staff to cleanse the area around the catheter and tubing every shift, but review of the treatment administration record showed that catheter care was not completed as ordered, with 20 missed opportunities out of 51 in the first 17 days of May. Documentation indicated that the resident refused care 16 times, but there were also shifts with no documentation of care or refusal. The resident, who was cognitively intact, reported that CNAs never performed catheter care and that only one nurse routinely provided it, while others did not even ask if care was wanted. An LPN stated they documented refusals without always offering care, and the DON confirmed that refusals should not be documented if care was not offered.