Failure to Provide and Document Catheter Care as Ordered
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received catheter care as ordered by the physician, and failed to document the provision of this care. The resident, who had diagnoses including neurogenic bladder and paraplegia, was dependent on staff for personal hygiene and had an order for catheter and peri care every shift, twice daily. Review of the Treatment Administration Record (TAR) and other documentation revealed multiple instances where staff did not initial or document completion of catheter care at the required times over a period of two months. Interviews with staff, including CNAs, a CMT, LPN, RN, the ADON, DON, and the Administrator, revealed inconsistent practices and uncertainty regarding who was responsible for completing and documenting catheter care. Some staff reported performing catheter care when emptying the catheter bag or during routine checks, while others were unsure if their colleagues were consistently providing or documenting the care. Several staff members indicated that if the TAR was blank, it likely meant the care was not completed or not documented, and some noted that documentation was the nurse's responsibility. The resident reported that staff emptied the catheter bag but only provided catheter care occasionally, with the last instance being the day before the interview. The resident also mentioned experiencing issues with catheter blockages and urinary tract infections. The facility did not provide a specific policy regarding catheter care, and the lack of documentation and inconsistent practices led to a failure to ensure the resident received catheter care as ordered, which is necessary to prevent urinary tract infections.