Failure to Assess, Document, and Plan Care After Catheter Removal
Penalty
Summary
The facility failed to provide appropriate care and services for a resident who was admitted with an indwelling urinary catheter. Upon admission, the resident had multiple diagnoses including urinary tract infection, overactive bladder, urinary retention, and required assistance with mobility and personal care. The resident's indwelling catheter fell out shortly after admission and was not replaced, but there was no documented assessment to determine the continued need for the catheter, nor was there a physician order to discontinue its use. Following the removal of the catheter, the facility did not conduct an assessment of the resident's bladder status or initiate a bladder training program as required by facility policy. There was also no documentation of alert charting to monitor for signs or symptoms of urinary retention or other complications after the catheter was removed. The resident's care plan was not updated to include interventions or an individualized bowel and bladder training program to address her needs after the catheter was discontinued. Interviews with nursing staff and the DON confirmed that there was no assessment for the need of the catheter, no physician notification or order for discontinuation, and no care planning or bladder training implemented after the catheter was removed. As a result, the resident was left to manage toileting without appropriate support, leading to multiple unassisted bathroom trips and several falls.