Failure to Document and Complete Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that catheter care and documentation of urinary output were completed as ordered for three residents with indwelling catheters. For one resident with obstructive and reflux uropathy, physician orders required catheter care and output documentation every shift, but review of the Medication Administration Record (MAR) revealed multiple shifts across three months with missing documentation. Nursing notes confirmed the resident experienced urinary tract infections during this period, and there was no additional documentation to verify catheter care or output. Another resident with neuromuscular dysfunction of the bladder also had orders for output documentation every shift, but the MAR showed several shifts without documentation, and no other records were available. A third resident with similar diagnoses had orders for catheter care and output documentation every shift, but the MAR again showed multiple shifts with missing entries and no other supporting documentation. Interviews with staff, including a unit manager, RN, and the DON, confirmed that there was no other documentation available to verify that catheter care or output documentation was completed as ordered for these residents. The RN and DON both stated that catheter care was performed each shift and that output was documented on the MAR, but acknowledged that when documentation was missing, there was no way to confirm the care was provided. Family and resident interviews also indicated concerns about catheter care and a history of urinary tract infections. Facility policy required catheter care to be completed as ordered to prevent infection, but the lack of documentation indicated noncompliance with these requirements.