Failure to Document and Provide Required Catheter Care and Output Monitoring
Penalty
Summary
The facility failed to provide proper care for residents with indwelling urinary catheters, as evidenced by a lack of documentation and adherence to care plans and facility protocols. For one resident with a Foley catheter placed due to a stage 4 pressure ulcer and urinary incontinence, the care plan required the catheter drainage bag to be changed twice monthly. However, there was no documented evidence that the drainage bag was changed on the specified dates, despite staff interviews confirming this was standard practice and part of the facility's protocol. The Director of Nursing acknowledged the absence of documentation for these required changes. Additionally, another resident with a suprapubic catheter had a care plan requiring urinary output to be measured and documented every shift. A review of the clinical record revealed multiple dates and shifts over several months where there was no documented evidence that urinary output was measured as required. The Director of Nursing confirmed the lack of documentation for these periods, indicating that the facility did not follow its own policy and the resident's care plan regarding urinary output monitoring.