Failure to Provide and Document Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide and document required treatment and services for a resident with an indwelling catheter. The resident, who was admitted with diagnoses including quadriplegia, spinal stenosis, and a history of TIA, was assessed as cognitively intact but fully dependent for activities of daily living. The resident's care plan and physician orders specified the need for regular catheter care every shift, daily catheter flushes, and monitoring of catheter output. However, review of the medication and treatment administration records over several months revealed multiple instances where these required treatments and monitoring were not documented as completed. Interviews with nursing staff confirmed that if catheter care was not documented, it was not performed. The facility's own urinary catheterization policy required licensed nurses to perform and document catheter care every shift. Despite these requirements, there was missing documentation for catheter output monitoring, catheter flushes, and catheter care on several shifts, indicating a failure to provide the ordered care and services for the resident's indwelling catheter.