Failure to Assess Ongoing Need for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to assess the appropriateness and continued use of an indwelling urinary Foley catheter for a resident who was cognitively intact and had a history of urinary retention and urinary tract infection. Medical record review showed a physician's order for the catheter but did not indicate the reason for its continued use. There was no documentation in the resident's medical record to show that the facility had assessed whether the catheter was still necessary or had attempted to remove it to determine if the resident could urinate independently. Interviews with nursing staff confirmed that the diagnosis of urinary retention alone was not an adequate indication for ongoing catheter use and that there was no evidence of reassessment or attempts at catheter removal. The resident reported not recalling how long the catheter had been in place and stated that the facility had not tried to remove it. The DON acknowledged these findings during the investigation.