Failure to Document Foley Catheter Re-Insertion in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Specifically, after a resident was found on the floor with her Foley catheter pulled out, the nurse responsible for re-inserting the catheter did not document the procedure in the resident's electronic medical record. The facility's policy requires that any insertion or re-insertion of a Foley catheter be documented, including details such as the time, gauge size, and the resident's tolerance of the procedure. The incident involved a female resident with a history of sepsis and vascular dementia, who was severely cognitively impaired. On the day of the event, staff responded to a scream and found the resident sitting on the floor with the Foley catheter removed. A head-to-toe assessment was performed, and no injuries were noted. The resident was unable to communicate what had happened. The nurse on duty at the end of her shift reported that another nurse agreed to re-insert the Foley catheter, but there was no documentation of this procedure in the medical record. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and Director of Nursing (DON), confirmed that the re-insertion of the Foley catheter was not documented as required by facility policy. Review of the facility's documentation policy further supported that all assessments, observations, and services provided must be recorded in the resident's medical record. The lack of documentation was verified through review of the electronic medical record and staff interviews.