Deficient Urinary Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate urinary catheter care for two residents, resulting in deficiencies related to catheter maintenance and documentation. For one resident with a urinary catheter, there were physician orders and a care plan in place to check and empty the catheter drainage bag twice per shift and when it was half full. However, observations revealed that the drainage bag was more than half full and had not been emptied as required, with a total of 1400 milliliters collected when finally emptied. The resident reported a recent urinary tract infection and stated that the catheter bag had previously overflowed due to lack of monitoring. Staff interviews confirmed that the expectation was to follow the care plan and orders, but the observed practice did not align with these requirements. For another resident with a urinary catheter, there was an order to document catheter output every shift, but no documented orders for catheter care, including frequency of catheter changes, catheter size, or instructions for emptying the drainage bag. Observations showed the resident had a urinary catheter in place, but staff were unaware of the need for specific catheter care orders. The Director of Nursing confirmed that standing orders for catheter use and care were expected but not present in the resident's records.