Failure to Document and Plan Care for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that appropriate physician's orders, documented medical justification, and an individualized plan of care were in place for the use and management of an indwelling urinary catheter for a resident admitted with a Foley catheter. Upon review, there was no documentation in the resident's care plan reflecting the presence of the catheter or the need for catheter-related care, despite the resident being admitted with the device. Additionally, the treatment administration record did not include entries documenting the catheter's presence, size, balloon volume, or instructions for nursing care, and there were no physician orders or medical justification for the catheter's use at the time of the surveyor's observation. Observation of the resident confirmed the presence of the Foley catheter, and interviews with the resident and facility staff verified that the catheter had been in place since admission. The Director of Nursing and Registered Nurse Assessment Coordinator acknowledged the absence of a physician order and a care plan for the catheter. Documentation and appropriate care planning were not initiated until several days after admission and only after the issue was identified by surveyors.