Failure to Initiate Baseline Care Plan and Document Care for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to initiate a baseline, person-centered care plan addressing an indwelling urinary catheter for one newly admitted resident. The resident was admitted with multiple diagnoses, including obstructive and reflux uropathy and a need for assistance with personal care, and had an indwelling urinary catheter in place for urinary retention following a failed voiding trial. Review of the resident’s care plans dated several days after admission showed there was no care plan addressing the risk of UTI related to the indwelling catheter. The SNF admission History & Physical documented that the catheter was in place and that a voiding trial would be considered the following week, and the MDS assessment confirmed the presence of an indwelling catheter and that the resident was always incontinent of stool. Subsequently, the resident developed a fever and low oxygen saturation, prompting a physician order for oxygen and transfer to the hospital. At the emergency department, the resident was found to have an elevated temperature, tachycardia, tachypnea, low-normal blood pressure, tacky mucous membranes, and an elevated white blood cell count consistent with infection. Urinalysis showed many bacteria and large leukocyte esterase, and the resident was admitted with sepsis due to a UTI. During interviews, the DON stated she could not find documentation of catheter care and confirmed there was no documented evidence of a person-centered care plan for the indwelling catheter, despite stating that a UTI risk care plan should be in place for all residents with indwelling catheters. The DSD reported that catheter care was not documented in residents’ charts because it was considered a standard of care. Facility policy on urinary catheter care required review of the resident’s care plan for special needs and detailed documentation of catheter care and related assessments, which was not reflected in this resident’s record.
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