Failure to Provide and Document Catheter Care and UTI Monitoring
Penalty
Summary
The facility failed to provide catheter care and monitoring in accordance with professional standards for three residents with indwelling catheters. For each resident, there were multiple instances where catheter output was not documented as required by physician orders and facility policy. In addition, the facility did not consistently monitor or report changes in eating patterns, which were identified in care plans as potential signs or symptoms of urinary tract infection (UTI). One resident with severe cognitive impairment and a history of atrial fibrillation, heart failure, and recent UTI had an indwelling catheter. The resident's treatment records showed missing documentation of catheter output on several shifts, and there was no evidence that changes in eating patterns were reported as required. The resident was hospitalized with severe sepsis due to UTI, with hospital records noting overt purulence in the catheter and abnormal urinalysis results. Another resident with neurogenic bladder and a suprapubic catheter also had multiple missed entries for catheter output and decreased nutritional and fluid intake that was not reported to the primary care physician. This resident was subsequently hospitalized for a complicated UTI, and the physician confirmed that notification should have occurred for decreased intake. A third resident with normal cognition and a history of anemia, renal insufficiency, and recent UTI also had an indwelling catheter. Documentation of catheter output was missing for several shifts across multiple months, and there was no supporting documentation in the medical record for these omissions. Interviews with nursing staff and facility leadership confirmed that lack of documentation indicated the task was not completed, and that the expectation was for catheter output to be recorded each shift as ordered. Facility policy required catheter bags to be emptied and output documented at least every eight hours, with unusual findings reported to the physician.