Failure to Assess Catheter Necessity and Follow Post-Removal Protocols
Penalty
Summary
The facility failed to evaluate the clinical necessity of an indwelling urinary catheter and did not follow its own policies regarding catheter removal and bladder assessment for a resident. Upon admission, the resident, who had end stage COPD and was receiving hospice care, had a Foley catheter in place. The facility's policy required the use of an assessment tool to determine the need for an indwelling catheter and mandated physician notification if criteria were not met. However, there was no documented diagnosis or clinical justification for the continued use of the catheter in the clinical record, and the required assessment was not completed. The care plan indicated assistance with toileting, but there was no supporting documentation for a toileting plan or continence pattern. After the hospice nurse recommended discontinuing the Foley catheter, the physician was contacted and the catheter was removed. Despite facility policy requiring a bladder assessment and initiation of a voiding trial following catheter removal, there was no documentation that these steps were completed. Subsequently, the resident experienced three falls while attempting to get to the bathroom. A later bladder assessment noted mixed urinary continence and a toileting schedule, but there was no documented bladder tracker to support this plan. The DON confirmed the lack of documentation and acknowledged that facility policy was not followed.