Failure to Document Catheter Care in Medical Record
Penalty
Summary
The facility failed to ensure that routine catheter care was documented in the clinical record for one resident with an indwelling urinary catheter. According to the facility's undated Catheter Care, Urinary policy, the date, time, and name and title of the individual providing catheter care should be recorded in the resident's medical record. A quarterly assessment showed the resident had moderate cognitive impairment, an indwelling urinary catheter, and diagnoses including acute kidney failure and diabetes mellitus. A review of the resident's medical record for three consecutive months revealed no documentation of catheter care. The resident reported receiving frequent catheter care, but both the ADON and DON confirmed that if catheter care was not documented, it could not be verified as completed.