Failure to Provide Consistent Indwelling Catheter Care
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide appropriate indwelling catheter care for a resident who was dependent on staff for all activities of daily living and had a history of cerebral infarction and multiple myeloma. Observation revealed the resident was in bed with a urinary Foley bag containing bright yellow, cloudy urine. Review of the medical record showed a physician order for catheter care every shift starting on 6/28/25, but there was no documentation that catheter care was consistently completed until 11/6/25. The Treatment Administration Record for November 2025 indicated staff documented catheter care twice daily, but there was no supporting documentation for the period from June to November 2025. Further review revealed that on 10/29/25, the resident was transported to the hospital, where the primary diagnosis was a urinary tract infection. Hospital records documented the presence of a chronic indwelling Foley catheter, a positive urinalysis for infection, and the need for intravenous antibiotics. Facility staff, including the Unit Manager and DON, were unable to provide documentation of catheter care for the resident during the specified period, and no further explanation or records were provided by the end of the survey.