Failure to Document Indication and Monitoring for Foley Catheter Insertion
Penalty
Summary
Staff failed to follow facility policy and procedures regarding the insertion and documentation of an indwelling (Foley) catheter for one resident. The resident was admitted with diagnoses including hypertension, osteoarthritis, and lack of coordination, and was assessed as having modified independence in cognitive skills and occasional urinary incontinence. The physician's order allowed for an in-and-out catheterization, with a Foley catheter to remain in place if residual urine exceeded 300 milliliters, but the order did not specify the indication for catheter use as required by facility policy. Upon review, there was no documentation of the indication for the Foley catheter, the time of insertion, or monitoring of intake and output in the resident's progress notes. Additionally, there was no documentation regarding the urine output, color, clarity, or the resident's tolerance of the procedure. The care plan for the Foley catheter was not developed at the time of insertion, and the required monitoring and documentation were not completed according to policy. Interviews with nursing staff and the Director of Nursing confirmed that the facility's policy and procedures were not followed. The staff acknowledged that the order lacked an indication and that documentation was incomplete. The Director of Nursing also confirmed that the comprehensive, person-centered care plan was not developed or implemented at the time of catheter insertion, as required by facility policy.