Failure to Provide Appropriate Catheter Care and Privacy
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling catheters, as evidenced by two specific cases. In the first case, a resident with moderate cognitive impairment and multiple diagnoses, including anxiety disorder, major depressive disorder, and heart failure, had an indwelling catheter placed without an appropriate supporting diagnosis. The resident's physician order indicated the catheter was for hospice/comfort, but there was no documented care plan addressing the catheter, and the Director of Nursing was unable to immediately provide the rationale or documentation for its use beyond referencing hospice notes. In the second case, another resident with a Foley catheter had a care plan specifying that the catheter bag and tubing should be positioned below the bladder and away from the entrance room door or covered for privacy. However, the catheter bag was observed hanging on the bed frame, facing the door, and visible from the hallway without a cover. The CNA responsible for the resident's care confirmed that the bag was not covered or repositioned as required, and the Director of Nursing acknowledged that the care plan interventions were not followed.