Failure to Document Catheter Care in Clinical Records
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for two residents who required documentation of catheter care. Specifically, on two separate night shifts, there was no documentation on the Treatment Administration Records regarding the emptying of catheter bags or the amount of drainage for both residents. The nurse assigned to those shifts confirmed that she was responsible for the documentation and acknowledged that the catheter bags were emptied by an aide, but she did not record the procedure or the amounts as required. Both residents had significant medical histories, including conditions such as Parkinson's Disease, dementia, parastomal hernia, benign prostatic hyperplasia, and major depressive disorder. The lack of documentation was confirmed through interviews with the nurse, the Administrator, and the DON, all of whom recognized the importance of accurate record-keeping. The facility's policy required regular assessment and documentation for residents using urinary devices, but this was not followed on the identified dates.