Failure to Change Indwelling Catheter and Monitor Post Void Residuals
Penalty
Summary
Facility staff failed to change an indwelling catheter and monitor post void residuals as ordered for a resident with obstructive and reflux uropathy. The resident required substantial to total assistance with activities of daily living and had a moderate cognitive impairment, as indicated by a BIMS score of 12. The resident's care plan included an order to change the indwelling catheter every 30 days, leave the catheter out, and monitor post void residuals, with instructions to replace the catheter if the residual volume exceeded 500 ml. Review of the Treatment Administration Record (TAR) for the specified month showed that the catheter change and post void residual monitoring, due on a particular date, were not documented as completed. The TAR also included an order for catheter care every shift. The Director of Nursing confirmed in an interview that the catheter was not changed as scheduled and that post void residuals were not monitored as required.