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F0690
D

Failure to Provide Proper Catheter Care and Documentation

Middletown, Pennsylvania Survey Completed on 12-04-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate catheter care and services to prevent urinary tract infections for a resident with a Foley catheter. Facility policy required that catheter tubing and bags be kept off the floor and that catheter care be documented with the date, time, and staff providing care. Observations on two separate occasions showed the resident's catheter bag in direct contact with the floor, contrary to policy. Staff interviews confirmed that the catheter bag should not have been on the floor. Additionally, review of the resident's clinical record revealed a lack of documentation for catheter care from the time of hospital readmission with a Foley catheter until several days later. Although there was a physician order for catheter care every shift, documentation was missing for multiple days and, when initiated, was only recorded for the day shift. The DON confirmed that catheter care should have been provided every shift, and the NHA acknowledged that the orders for catheter care were not re-populated until several days after the resident's return.

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