Failure to Provide Catheter Care and Output Monitoring per Physician Orders
Penalty
Summary
The facility failed to provide care and services for a urinary catheter according to physician orders for a resident with paraplegia, neurogenic bladder, and a history of sepsis and catheter-related infection. The resident had physician orders to have the catheter emptied and urine output recorded three times daily, with documentation required in the electronic clinical record. Review of the Medication and Treatment Administration Record (MAR/TAR) revealed multiple instances across several months where the required documentation was missing, indicating that the catheter may not have been emptied or the output recorded as ordered. There was no evidence in the clinical record that the resident refused care on these occasions. Interviews with the resident confirmed that the catheter bag was not always emptied as scheduled, with reports of the bag not being emptied for 12-14 hours at times, and the resident having to empty the bag himself. Staff interviews corroborated that both CNAs and nurses are responsible for catheter care and output monitoring, and that failure to empty the catheter bag as ordered could lead to complications. The Assistant Director of Nursing and the Director of Nursing both acknowledged the importance of adhering to physician orders for catheter care and recognized that the lack of documentation meant there was no way to confirm if care was provided as required. Facility policy required regular emptying of catheter bags and documentation to prevent infection and ensure proper care. The policy also specified the use of clean containers and ongoing monitoring for signs of infection. The review of records and staff interviews demonstrated that the facility did not consistently follow these protocols, resulting in a failure to provide care and services in accordance with physician orders and established standards.