Failure to Provide and Document Required Catheter Care and Monitoring
Penalty
Summary
A deficiency was identified regarding the care and management of a resident with a Foley catheter. The resident, who had multiple diagnoses including cardiac arrest, open wound, malnutrition, spinal stenosis, vascular disease, dysphagia, muscle weakness, intellectual disabilities, and urinary retention, was admitted with a Foley catheter in place due to obstructive uropathy. The care plan indicated the need for regular catheter care, monitoring of urine output, and prompt physician notification of any changes. However, review of the medical record revealed no evidence that catheter care was provided or that urine output was measured and documented from July through September. Additionally, there were no documented physician orders for the catheter prior to late September. An incident occurred when the resident's catheter came out overnight. The resident reported waiting for a nurse to replace it, but staff interviews revealed that the night nurse did not attempt to replace the catheter or notify the physician. The following day, the LPN on duty discovered the lack of catheter orders and contacted the physician for clarification. The RN on duty also did not replace the catheter or notify the physician, citing the absence of orders. There was no documentation of the resident's urine output during the 16-hour period without a catheter, nor was there evidence of physician notification regarding the catheter's removal. Facility policy required prompt physician notification of significant changes, regular catheter care each shift, and comprehensive care planning. Interviews with the DON and other staff confirmed that catheter care was not documented for several months and that the lack of orders was an oversight. The deficiency was substantiated by the absence of documentation, lack of physician notification, and failure to provide required catheter care and monitoring as outlined in facility policy.