Failure to Accurately Document and Timely Provide Catheter Care
Penalty
Summary
The facility failed to ensure that the medical record for a resident was complete and accurately documented, specifically regarding the timing and documentation of catheter care. The resident, a forty-one-year-old male with paraplegia, major depressive disorder, and ankylosing spondylitis, was care planned for self-catheterization with nursing staff monitoring and documenting intake and output. Physician orders required in-and-out catheterization every six hours at set times. On the date in question, the Medication Administration Record (MAR) reflected catheter care at 4:00 am, 10:00 am, and 10:00 pm, but there was no entry for the 4:00 pm scheduled time. Interviews and record reviews revealed that the resident actually received catheter care at approximately 6:30 pm, not at the documented 10:00 pm time. The resident reported experiencing significant pain due to the delay in catheter care, stating that he requested assistance multiple times and only received care about 2.5 hours after the scheduled time. He also reported needing pain medication due to the discomfort. Multiple staff interviews confirmed the delay, with one LPN stating she provided catheter care at 6:30 pm after the resident complained of pain. The Assistant Director of Nursing (ADON) and other staff acknowledged that the resident's care was delayed due to attending to other residents in pain, and that the catheter care was not documented as a late entry but instead was inaccurately recorded as being performed at 10:00 pm in the MAR. Further interviews with nursing and administrative staff confirmed that the delay in catheter care was not communicated during shift change, and that the nurse responsible did not document the actual time of care. Staff also discussed the potential for discomfort and pain when catheter care is delayed, and acknowledged that orders should be followed and documentation should be accurate. The facility's policy emphasized the importance of prompt response to resident needs and maintaining dignity, but the events described showed a failure to meet these standards in this instance.