Failure to Provide and Document Foley Catheter Care per Facility Policy
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident with an indwelling Foley catheter. Facility policy on urinary catheter care, revised in September 2014, required staff to wash the genitalia and perineum with soap and water, rinse and dry the area, cleanse and rinse the catheter from the insertion site approximately four inches outward, and document the date and time catheter care was given, the name and title of the person providing care, and all assessment data obtained. Review of the resident care policies and clinical documentation showed that these required catheter care procedures and documentation elements were not present in the resident’s medical record. The resident involved had diagnoses including neuromuscular dysfunction of the bladder, urinary retention, and a cognitive communication deficit, and had an order for an indwelling Foley catheter with gravity drainage for urinary retention. The catheter was originally ordered in November 2025, with a current order dated in December 2025. Review of the clinical record, including physician orders and treatment administration records from early December 2025 through mid-January 2026, revealed no orders for catheter care and no documentation that catheter care or drainage bag emptying had been provided during that period. In interviews, the Nursing Home Administrator and Director of Nursing were informed of the concern, and the Nursing Home Administrator later confirmed that the resident did not have catheter care orders in place, despite the ongoing catheter order.
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