Failure to Document and Provide Appropriate Catheter Care
Penalty
Summary
A deficiency was identified when a resident with a urinary catheter did not receive appropriate catheter care and documentation as required by facility policy. Observation revealed the resident had a urinary catheter, and review of the clinical record showed that after the resident was readmitted from the hospital with a Foley catheter, there were no physician's orders for catheter care. Additionally, there was no documentation of input and output or catheter care provided during the period the catheter was in place. Facility policy required that catheter care, including assessment data, problems noted, and resident tolerance, be documented in the medical record, along with the date, time, and staff involved. An interview with licensed staff confirmed the absence of documentation regarding the catheter from the time of readmission until the catheter was removed. This lack of documentation and absence of physician orders for catheter care constituted a failure to provide appropriate catheter treatment and services for the resident.