Failure to Document and Perform Urinary Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that urinary catheter care was completed and documented for three of four residents with indwelling urinary catheters. Facility policy required daily catheter care to be documented in the electronic health record (EHR), and physician orders for the affected residents specified that catheter care was to be performed every shift. However, clinical record reviews revealed no evidence that catheter care was documented for these residents as required by both policy and physician orders. Specifically, one resident with obstructive uropathy and type 2 diabetes mellitus had an indwelling catheter in place, but there was no documentation of catheter care until a specific date several months after the order was in place. Another resident with urinary retention and cerebral palsy also had an indwelling catheter, with orders and care plans specifying catheter care every shift, but the treatment administration record did not show that this care was being completed or signed off. A third resident with urinary retention and a long-standing catheter similarly had no documentation indicating that catheter care was performed every shift as ordered. These findings were confirmed by interviews with the DON, who acknowledged the lack of documentation for all three residents.