Failure to Provide and Document Indwelling Catheter Care and Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling catheter received proper care and monitoring. Upon admission, the resident had a new indwelling catheter, but staff did not place an order for catheter care or monitoring. Record review confirmed there was no documentation of catheter care or monitoring, and staff interviews revealed that the omission was recognized by both an LVN and an RN. The staff acknowledged that they did not monitor the resident for signs and symptoms of catheter complications, nor did they track intake and output as required. The resident in question had multiple diagnoses, including COPD, acute respiratory failure, and severe cognitive impairment, and required maximal assistance with activities of daily living. Facility policy required observation for catheter complications and documentation of catheter care, including assessment data and urine characteristics. However, these procedures were not followed, and there was no record of catheter care being provided or monitored for this resident.