Failure to Assess and Discontinue Indwelling Catheter After Resolution of Pressure Injuries
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling urinary catheter was properly assessed for catheter removal as soon as possible, and did not ensure that a clinical justification existed for the continued use of the catheter. The facility's policy required a medical justification for both the initiation and ongoing use of indwelling catheters, including a Bladder Data Collection/Evaluation and a plan of care documenting justification for continued catheterization beyond 14 days. For the resident in question, who was cognitively intact and dependent on staff for toileting, the initial justification for the catheter was the presence of Stage 3 pressure injuries to the sacrum and right buttock. Subsequent wound care consults documented that both pressure injuries had resolved, and a recent Bladder Data Collection and Evaluation did not identify any ongoing conditions that would justify continued catheter use. Despite this, the catheter remained in place, and staff confirmed that no action was taken to contact the provider for a trial discontinuation order after the wounds had healed. The resident's medical record did not contain diagnoses such as obstructive uropathy, neurogenic bladder, benign prostate hyperplasia, or urinary retention that would otherwise justify the catheter's continued use.