Failure to Document Catheterization Attempts and Physician Notification
Penalty
Summary
The facility failed to maintain complete, accurate, and systematically organized medical records for a resident with dementia and urinary retention requiring an indwelling urinary catheter. Licensed vocational nurses (LVN A and LVN B) did not document failed attempts to change the resident's urinary catheter, nor did they record the report to the physician regarding the change in the resident's condition. The medication administration record indicated that the catheter was instilled, but there was no detailed documentation in the medical record about the procedure, complications encountered, or communication with the physician. The resident, an elderly male with dementia and an enlarged prostate, was admitted for long-term care and required substantial assistance with activities of daily living. Physician orders specified regular care and monthly changes of the indwelling urinary catheter. On the day of the incident, LVN A attempted to change the catheter but met resistance and had no urine return. She reported this to LVN B but did not document the details of the procedure or the nurse-to-nurse report. LVN B also attempted the procedure without success and subsequently contacted the physician, who ordered the resident's transfer to the hospital. However, LVN B also failed to document the sequence of events and communication with the physician in the medical record. Interviews with the resident's representative and facility staff confirmed the lack of documentation regarding the failed catheterization attempts, the resident's change in condition, and the physician notification. The facility's policy and professional guidelines require detailed documentation of such procedures, including assessment findings, complications, and communication with practitioners, but these were not followed in this case.