Failure to Maintain Accurate Foley Catheter Orders and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident who was readmitted from the hospital with a Foley catheter. Upon review, it was found that the resident's November administration orders did not include any orders for Foley catheter care, despite the resident having an indwelling catheter in place. The resident's care plan and physician order summary indicated the presence of a Foley catheter and outlined care interventions, but these were not reflected in the administration record, which is used by nursing staff to document care provided. Interviews with staff confirmed that the resident returned from the hospital with a Foley catheter and that care, such as cleaning the insertion site and changing the drainage bag, was being provided. However, staff also stated that there should have been specific orders for Foley catheter care in the administration record to ensure proper documentation and completion of required tasks. The Director of Nursing acknowledged that the Foley catheter order was entered into the electronic medical record but was not activated on the administration record, resulting in a lack of documentation for the care provided. Record reviews further showed that the facility had a policy requiring catheter care every shift and as needed, and that staff had received in-service training on Foley catheter care. Despite this, the absence of Foley catheter care orders in the administration record meant that the care provided was not properly documented, which could affect the accuracy and completeness of the resident's clinical records.