Failure to Assess and Attempt Removal of Indwelling Catheter
Penalty
Summary
The facility failed to ensure that a resident admitted with an indwelling catheter (I/C) was properly assessed for the continued need for the catheter and that attempts were made to remove it as soon as possible. Upon admission from the hospital, the resident had an I/C in place, but there was no documentation in the medical record indicating an assessment of the reason for the catheter, nor evidence that staff consulted with a provider regarding its necessity. The resident's bowel and bladder assessment indicated incontinence, but no further evaluation or trial removal of the catheter was documented. Staff interviews confirmed that the required assessment and trial removal were not performed, and there was no documentation of post void residual (PVR) measurements or provider consultation as per facility protocol. Observations showed the resident with the I/C in various positions, including lying in bed and sitting in a wheelchair, with the catheter bag sometimes resting on the floor. The care plan and physician orders directed staff to provide catheter care every shift, but the critical step of reassessing the need for the catheter and attempting its removal was omitted. The lack of assessment and documentation regarding the ongoing need for the I/C constituted a failure to follow established protocols and placed the resident at risk for complications associated with prolonged catheter use.