Failure to Document Urinary Catheter Change
Penalty
Summary
Nursing staff failed to maintain a complete and accurate medical record for a resident with Cauda Equina Syndrome and neuromuscular bladder dysfunction. The resident had physician orders allowing nursing staff to change an indwelling urinary catheter as needed for blockage or dislodgement. Despite these orders, there was no documentation in the resident's medical record or Treatment Administration Record (TAR) indicating that a catheter change occurred during the relevant period. An internal investigation revealed that a nurse changed the resident's Foley catheter at the resident's request due to discomfort and blockage, but did not document the procedure anywhere in the medical record. The nurse confirmed during an interview that the catheter change was performed but not recorded. The Director of Nursing also acknowledged that the catheter change should have been documented and that daily care related to indwelling catheters was not being properly recorded.