Failure to Provide and Document Catheter Care per Facility Policy
Penalty
Summary
The facility failed to provide adequate catheter care for two residents with indwelling urinary catheters, as required by facility policy. The policy specified that perineal care should be performed every eight hours, the collection bag should be emptied at least every eight hours and as needed, the catheter should be cleansed from the insertion site outward, and the drainage tubing and bag should be checked to ensure proper drainage and that the catheter was kept off the floor. For one resident with urogenital implants, a physician's order for foley catheter care every shift was discontinued, and no new order was placed, despite the resident continuing to have a foley catheter. There was no evidence that catheter care was provided to this resident after the order was discontinued. Another resident with diabetes mellitus and urinary retention had an order for an indwelling catheter. Multiple observations over several days confirmed the presence of the catheter, but there was no documented evidence that staff provided catheter care according to facility policy. The Infection Preventionist confirmed the lack of documentation for catheter care for both residents.