Deficient Catheter Care and Documentation
Penalty
Summary
A deficiency was identified regarding the care and management of an indwelling Foley catheter for one resident. The resident, who had a history of severe intellectual disabilities, hydronephrosis, urinary retention, and recurrent urinary tract infections, was observed multiple times with the urinary drainage bag positioned above the level of the bladder while seated in a wheelchair. The bag was attached to the wheelchair armrest, contrary to facility policy and standard practice, which require the drainage bag to be kept below bladder level to prevent backflow of urine. Additionally, the resident was not wearing a urinary collection leg bag as specified in the care plan when out of bed. Record review revealed that there were no provider orders in place for the indwelling Foley catheter, including orders for its care or for scheduled catheter changes, despite hospital discharge instructions specifying monthly changes. The resident's comprehensive care plan and Kardex contained inaccuracies, such as references to a suprapubic catheter and nephrostomy tube that the resident did not have. The care plan was not updated to reflect the resident's current urinary status or device needs, and staff interviews confirmed a lack of awareness and follow-through regarding the required catheter care and documentation. Staff interviews further indicated that responsibilities for updating care plans, obtaining provider orders, and ensuring accurate documentation were not consistently fulfilled. Nursing staff and aides were unclear about the correct use of leg bags and the proper placement of drainage bags, and there was a lack of communication regarding changes in the resident's condition and device requirements. The facility's failure to ensure appropriate catheter care, accurate care planning, and proper provider orders led to the identified deficiency.