Failure to Complete Comprehensive Assessment After Catheter Removal
Penalty
Summary
The facility failed to provide care and treatment consistent with professional standards of practice for one resident who was re-admitted following a hospitalization and removal of an indwelling catheter. After the resident returned to the facility without the catheter, there was no documentation of comprehensive assessments or monitoring of the resident's ability to void or for potential complications, as required by the nursing process outlined in the Wisconsin Nurse Practice Act. Specifically, there was a lack of documentation from the day after re-admission through the following day, and the Director of Nursing acknowledged that the resident was not assessed or monitored appropriately after re-admission. Interviews with facility leadership revealed that there was no current policy on comprehensive assessments and nurse documentation at the time of the incident. The Director of Nursing and Regional Clinical staff reported that the facility had previously identified concerns with nursing assessments and documentation during a recent re-certification survey and were in the process of developing new policies, procedures, and documentation tools, but these were not yet implemented at the time of the deficiency.