Failure to Maintain Accurate Medical Records for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who had an indwelling urinary catheter. The resident, who had multiple diagnoses including high blood pressure, diabetes, Parkinson's disease, hypothyroidism, and systemic lupus erythematosus, was admitted to hospice care and had a Foley catheter placed for urinary retention. Although there was a handwritten order from the initial hospice physician for the catheter, this order was not entered into the electronic clinical record, and no new order was documented when the resident transitioned to a second hospice provider. Additionally, the order to discontinue the first hospice provider was not documented. Review of the resident's care plans and clinical records revealed inconsistencies and omissions. The quarterly MDS assessment did not indicate the presence of an indwelling urinary catheter, despite care plans and nursing notes referencing its use. The electronic physician order summary lacked any order for the catheter, and there was no documentation of catheter care being provided after the resident switched hospice providers. Nursing notes confirmed the presence and replacement of the catheter, but these actions were not consistently documented in the resident's official medical record. Interviews with nursing staff and the DON confirmed that there was no order for the indwelling urinary catheter in the electronic record and that documentation of catheter care was missing. The DON and Administrator acknowledged that the absence of proper orders and documentation could result in missed care. The facility's policy requires maintenance of complete medical records in accordance with professional standards, but this was not followed in the resident's case.