Failure to Provide and Document Required Catheter and Nephrostomy Care
Penalty
Summary
The facility failed to provide appropriate nephrostomy and urinary catheter care, as well as to document urinary output as ordered, for one resident reviewed for bowel and bladder care. According to the facility's policy, catheter care and nephrostomy tube care were to be completed every day and night shift, and urinary output was to be recorded every shift. However, documentation showed that catheter flushes, catheter care, nephrostomy care, and output monitoring were frequently missed or only completed once daily instead of twice, and in some instances not done at all on certain days. The resident was unsure if care was being performed as required. The Infection Preventionist/Treatment Nurse confirmed that if care was not signed out, it was not completed as ordered, and that refusals should be documented in the progress notes, which was not consistently done.