Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
A deficiency occurred when a male resident with a history of hemiplegia, hemiparesis, cerebral infarction, and Wernicke's encephalopathy was admitted to the facility with an indwelling Foley catheter. Despite clear documentation from the hospital regarding the presence of the catheter and the need to prevent infection, the facility failed to obtain or document physician orders for catheter care, monitoring for signs and symptoms of infection, or monitoring of urinary input and output. The resident's care plan referenced catheter care interventions, but these were not supported by corresponding orders or consistent documentation in the medical record. Throughout the resident's stay, there was a lack of skilled nursing notes regarding catheter assessments or urine output measurements. Multiple progress notes and assessments referenced the presence of a Foley catheter, but there was no evidence of routine monitoring or documentation of catheter care. Interviews with staff revealed confusion and lack of recall regarding the resident's catheter status, and several staff members indicated that if catheter care was not documented, it likely was not performed. The absence of catheter care orders in the electronic medical record meant that necessary care tasks were not prompted or completed. The resident experienced multiple falls, confusion, and ongoing antibiotic treatment for a urinary tract infection. Ultimately, the resident was hospitalized and diagnosed with sepsis, with hospital records noting a distended bladder and recommendations to assess for catheter dysfunction. Interviews with facility staff and the resident's family confirmed that catheter care was not adequately managed, and the lack of orders and monitoring contributed to the resident's decline and hospitalization.