Failure to Document Clinical Indication for Indwelling Catheter
Penalty
Summary
The facility failed to ensure that appropriate treatments and services were provided for the use of an indwelling urinary catheter for one resident. Specifically, the clinical record for a resident admitted with diagnoses including high blood pressure, hyperlipidemia, and muscle weakness showed a physician's order for an indwelling urinary catheter, but the order did not include a required diagnosis for the catheter. Review of facility policy indicated that clinical indications for catheter use should be reviewed and documented prior to insertion, and the ongoing need for the catheter should be assessed and documented by nursing and the interdisciplinary team. This deficiency was confirmed during an interview with a registered nurse, who acknowledged the failure to provide the required documentation and assessment for the catheter use.