Failure to Provide Comprehensive Catheter Care and Services
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter. The resident, who had a history of multiple urinary tract infections and had required a catheter for 14 months, reported needing assistance with catheter care and expressed hope for improved care following a recent urology appointment. Review of the resident's medical record revealed that physician's orders only specified the monthly catheter change, with no additional orders regarding the frequency or specifics of catheter care. The resident's care plan addressed only fall risk and enhanced barrier precautions related to the catheter, omitting any individualized interventions or services for catheter care and prevention of urinary tract infections. A nursing note indicated the presence of blood in the catheter bag prior to a doctor's appointment, but no further documentation of catheter care was found. Interviews with facility staff, including the Regional Nurse Consultant and the Director of Nursing, confirmed that the care plan was incomplete and lacked necessary details regarding catheter care. Both staff members acknowledged that the care plan should have included services and care for the catheter, and that there were missing physician orders related to catheter care. Review of facility policies indicated that baseline and comprehensive care plans should address all resident-specific health concerns and services, but these requirements were not met for this resident.