Inaccurate Assessment of Resident with Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure the accuracy of assessments for a resident with an indwelling urinary catheter. Record review and interviews revealed that the resident was admitted with an indwelling urinary catheter and continued to receive catheter care as ordered by a physician and documented in treatment records. However, the quarterly assessment inaccurately coded the resident as 'always incontinent of urine' instead of reflecting the presence of the indwelling catheter. The Director of Nursing acknowledged that the assessment should have been coded as 'not rated' rather than indicating incontinence, as the resident had a catheter in place during the assessment period. This deficiency was identified through observation of catheter care, review of medical records, and staff interviews, which confirmed the inconsistency between the resident's actual condition and the documentation in the assessment.