Indwelling Urinary Catheter Inserted Without Clinical Indication or Resident Education
Penalty
Summary
A deficiency occurred when a resident was provided with an indwelling urinary catheter without a documented clinical indication, contrary to facility policy and evidence-based guidelines. The resident, who had diagnoses including dependence on renal dialysis, benign prostatic hyperplasia, and schizophrenia, was cognitively intact and had previously demonstrated the ability to void freely after a trial without a catheter. Despite this, the resident requested a catheter due to urinary incontinence, and staff proceeded with the insertion based on the resident's wishes and a physician's note, but without a valid clinical justification such as urinary retention, wound care, or hospice care. The facility's policy required that indwelling urinary catheters be used only after assessment and documentation of valid clinical indications, and that staff provide education to the resident regarding the clinical implications and risks associated with catheter use. In this case, the order for catheter insertion did not specify the catheter size, and there was no documentation that the resident was counseled about the risks or clinical implications of catheter use. Interviews with nursing staff and the physician confirmed that the catheter was inserted primarily due to the resident's request and not for a clinical reason recognized by facility policy. Additionally, the medical record lacked evidence of staff providing the required education to the resident prior to catheter insertion. The Director of Nursing Services acknowledged that catheter insertion should be reserved for specific clinical indications and not for convenience. The deficiency was identified during an abbreviated survey, with findings supported by record review and staff interviews.