Failure to Ensure Proper Catheter Management and Documentation
Penalty
Summary
The facility failed to ensure proper management and documentation of a urinary catheter for a resident during their stay. Upon admission, neither the hospital discharge orders nor the facility's admission orders included documentation of a urinary catheter, despite the resident having one in place as noted in the nurse admission assessment. There was no physician's order for the catheter, no documented clinical indication for its use, and no plan for its removal when no longer clinically indicated. Daily nursing assessments from 6/14 to 6/17 did not identify the presence of the catheter or document any related care needs or signs of urinary tract infection (UTI). On 6/16, staff noted abnormal urine characteristics and notified the medical provider, who ordered a urinalysis, but the results were not available at the time of the resident's discharge. When the resident was transferred to another facility, the catheter was found to have significant sediment, and there was no communication from the discharging facility regarding a possible UTI or that a urine sample had been obtained. The receiving facility subsequently removed the catheter and started the resident on antibiotics for a UTI. Interviews with facility staff confirmed that required processes for catheter management, including obtaining physician orders, documenting medical necessity, and planning for removal, were not followed. The facility's own CAUTI prevention guidelines were not adhered to, contributing to the deficiency.