Failure to Provide and Document Daily Catheter Care for Resident with Foley Catheter
Penalty
Summary
A deficiency was identified when a resident with an indwelling Foley catheter did not receive appropriate catheter care to prevent urinary tract infections over several months. The resident, who had diagnoses including spina bifida, constipation, and urinary retention with obstructive and reflux uropathy, was cognitively impaired but generally able to communicate and understand with some difficulty. The facility's policy required daily catheter care to be documented, including assessment data and any issues noted during care. However, record review showed there was no documented physician order for daily catheter care until late August, and there was no evidence in the nursing progress notes that catheter care was provided from May through August. Interviews with nursing staff revealed that catheter care was typically performed with peri care and documented when prompted by an order in the electronic system. Staff indicated that if there was no order in the system, they would not be prompted to perform or document the care. Some staff stated they would still perform the care and document it in progress notes, but no such documentation was found for the period in question. The deficiency was cited under 10 NYCRR 415.12(d)(1) for failure to ensure appropriate catheter care and services to prevent urinary tract infections.