Failure to Provide and Document Catheter Care for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to provide appropriate catheter care and services for three residents with indwelling urinary catheters. For one resident with paraplegia and neurogenic bladder, the care plan and physician orders required catheter care every shift and as needed, but there was no documentation that this care was ever performed. The resident expressed dissatisfaction with the care, stating she often had to care for her own catheter due to lack of trust in staff. Staff interviews revealed that some nurses were inexperienced or untrained in catheter care, and there was confusion about how to document care or refusals. Another resident with a history of femur fracture and neurogenic bladder had a urinary catheter but did not have any catheter care interventions documented from admission until the time of the survey. Orders for catheter care and enhanced barrier precautions were only entered on the day of the survey, and the Director of Nursing (DON) could not explain what care had been provided prior to that date. The resident confirmed having the catheter for several weeks, but there was no evidence of appropriate care or documentation during that period. A third resident with a suprapubic catheter following bladder removal for cancer also lacked appropriate catheter care orders until the day of the survey. Previous orders were for an indwelling catheter, which the resident did not have, and these were only corrected during the survey. The DON acknowledged that orders and documentation for catheter care had been missed for all three residents and was unable to provide evidence of care or explain the process failures that led to the deficiencies.